Community Health Center of Fort Dodge, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Eagle Grove, IA
NPI 1801596325 · NPPES record last updated Mar 3, 2023
Key facts
- NPI
- 1801596325
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- COMMUNITY HEALTH CENTER OF FORT DODGE, INC.
- Practice address
- 306 W Broadway St
Eagle Grove, IA 50533-1712 - Phone
- (515) 576-6500
- Fax
- (515) 576-1951
- NPI assigned
- Mar 3, 2023
- Organization subpart
- Yes
- Parent organization (as reported)
- COMMUNITY HEALTH CENTER OF FORT DODGE, INC.
Authorized official
- Name
- Renae Irene Elizabeth Kruckenberg
- Title
- Ceo
- Phone
- (515) 576-6500
Owned or controlled facilities with NPI records 2
Other NPIs on the same Medicare enrollment 5
Other NPIs with the same Medicare PAC ID 6
Corporate family (same tax ID) 4
Practitioners 31
-
Angela Marie Crosby, LMHC
-
Janet E Secor, DO
-
Lisa Kay Chase, ARNP
-
Jennifer Saari Zigrang, ARNP
-
Julie M Beehler, ARNP
-
Serene Marie Bolinger, MS ED
-
Jessica Rae Doolittle, ARNP
-
Ann Marie Feser, NP-C
-
Roxanne Lee Fevold, LMHC
-
Eileen Meier, PMHNP-BC
-
Rebecca Kay Mooney, PMHNP
-
Kirsten J Olson, LISW
-
Jennifer Leigh Pudenz, FNP-BC
-
Tayler Marie Rasch, ARNP
-
Sandra Rohr, ARNP
-
Bailey Jo Schutz, FNP-C
-
Elizabeth Webster Stoebe, D.O.
-
Rebecca Ann Pearce, ARNP
-
Deborah Price, PMHNP
-
Amber Aria, OD
-
Naarah L Hauenstein, MSPA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 16D2281576 | Community Health Center of Eagle Grove | Provider-performed microscopy | May 8, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IA
Federally qualified health center certification: CCN 161007
- Legal name
- COMMUNITY HEALTH CENTER OF FORT DODGE INC
- Doing business as
- COMMUNITY HEALTH CENTER OF EAGLE GROVE
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jun 7, 2023
- Last certification
- Jun 7, 2023
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 19, 2003 in IA
- Enrollment address
- 306 W Broadway St
Eagle Grove, IA 50533-1712
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Renae Kruckenberg |
Corporate Director |
Mar 1, 2023 | 100% |
| Jana Woodruff |
W-2 Managing Employee |
Mar 1, 2023 | 100% |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Community Health Center of Dayton |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (5%) 5% Or Greater Security Interest (5%) Operational/Managerial Control (5%) |
Jul 1, 2014 Jul 1, 2014 Jul 1, 2014 |
| Community Health Center of Spencer |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (5%) Operational/Managerial Control (5%) |
Jan 1, 2025 Jan 1, 2025 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
| O20230612000391 | IA | Part a Provider - Federally Qualified Health Center (FQHC) | 1557378627 | Practice locations: Eagle Grove, IA |
National Provider Directory
- Tax ID family
- Community Health Center Inc
- Part of
- Community Health Center Inc
Locations
303 N Main St
Clarion, IA 50525
Phone (515) 532-3343
126 N 10th St
Fort Dodge, IA 50501
Phone (515) 576-6500
404 N Federal Ave
Mason City, IA 50401
Phone (641) 450-0601
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
306 W Broadway St
Eagle Grove, IA 50533-1712
Mailing address
126 N 10TH St
Fort Dodge, IA 50501-3915
Phone (515) 576-6500
Other names
- Community Health Center of Eagle Grove
Other providers in Eagle Grove, IA
- Broadway Vision Source, Incorporated
- Gregory Jon Burmeister
- City of Eagle Grove
- Coleman Counseling, Inc.
- Jill Coleman
- Michele Diane Cooper
- Eagle Grove C.S.D.
- Eagle Grove Chiropractic PLC
- Eagle Grove Community School District
- Eagle Grove Family Dentistry PLC
All providers in Eagle Grove, IA · Federally Qualified Health Center (FQHC) in Iowa
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 3, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.