NPIMap

Organization Active NPI

Community Health Center of Fort Dodge, Inc.

  • Federally Qualified Health Center (FQHC)
  • Dayton, IA
National Provider Identifier
1689087215
Registry record updated Mar 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY HEALTH CENTER OF FORT DODGE, INC.
Practice address
24 S Main St
Dayton, IA 50530
Phone
(515) 547-2974
Fax
(515) 547-2976
NPI assigned
Jun 11, 2014
Last updated
Mar 1, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
COMMUNITY HEALTH CENTER OF FORT DODGE INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 1, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Renae Irene Elizabeth Kruckenberg
Title
Ceo
Phone
(515) 576-6500

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

24 S Main St
Dayton, IA 50530

Mailing address

24 S Main St
Dayton, IA 50530-7698
Phone (515) 576-6500

Other names 1

  • Community Health Center of Dayton Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070104000109 IA Part B Supplier - Clinic/Group Practice 1557378627 Receives reassigned benefits from 33 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Spencer, IA; Mason City, IA; Fort Dodge, IA; Dayton, IA; Eagle Grove, IA; Clarion, IA
O20180820001950 IA Part A Provider - Federally Qualified Health Center (FQHC) 1557378627 Practice locations: Dayton, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1689087215. Details of each certification follow.

Federally qualified health center certification: CCN 161885

Legal name
COMMUNITY HEALTH CENTER OF FORT DODGE INC
Doing business as
COMMUNITY HEALTH CENTER OF DAYTON
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 20, 2018
Last certification
Aug 20, 2018
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
24 S Main St
Dayton, IA 50530-7698

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D2085625Community Health Center of Dayton24 South Main Street, Dayton, IA 50530Provider-performed microscopyOct 16, 2026

National Provider Directory

National Provider Directory
Tax ID family
Community Health Center Inc5 organizations share this tax ID, including this one
Part of
Community Health Center Inc

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Community Health Center of Fort Dodge Inc Organization, Fort Dodge, IA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2014 5%
5% Or Greater Security Interest Jul 1, 2014 5%
Operational/Managerial Control Jul 1, 2014 5%
Renae Kruckenberg Individual Corporate OfficerCeo Jul 1, 2014
Operational/Managerial ControlCeo Jul 1, 2014

Owners & managing parties with NPI records 6

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Community Health Center of SpencerSpencer, IA, CCN 161040 Federally qualified health center 5% Or Greater Direct Ownership Interest (5%)
Operational/Managerial Control (5%)		 Jan 1, 2025
Jan 1, 2025

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1402444800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1677628800000",
    "number": "1689087215",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24 S MAIN ST",
            "city": "DAYTON",
            "state": "IA",
            "postal_code": "505307698",
            "telephone_number": "515-576-6500",
            "fax_number": "515-576-1951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24 S MAIN ST",
            "city": "DAYTON",
            "state": "IA",
            "postal_code": "50530",
            "telephone_number": "515-547-2974",
            "fax_number": "515-547-2976"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTER OF FORT DODGE, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY HEALTH CENTER OF FORT DODGE INC.",
        "enumeration_date": "2014-06-11",
        "last_updated": "2023-03-01",
        "certification_date": "2023-03-01",
        "status": "A",
        "authorized_official_last_name": "KRUCKENBERG",
        "authorized_official_first_name": "RENAE",
        "authorized_official_middle_name": "IRENE ELIZABETH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "515-576-6500"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Health Center of Dayton",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Dayton, IA

Sources for this page

Verify at the official NPI Registry.