NPIMap

Organization Active NPI

Community Health Center of Fort Dodge, Inc.

Doing business as Community Health Center of Eagle Grove

  • Federally Qualified Health Center (FQHC)
  • Eagle Grove, IA
National Provider Identifier
1801596325
Registry record updated Mar 3, 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.
Doing business as
Community Health Center of Eagle Grove
Practice address
306 W Broadway St
Eagle Grove, IA 50533-1712
Phone
(515) 576-6500
Fax
(515) 576-1951
NPI assigned
Mar 3, 2023
Last updated
Mar 3, 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 3, 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

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 1

  • Community Health Center of Eagle Grove Doing business as

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
O20230612000391 IA Part A Provider - Federally Qualified Health Center (FQHC) 1557378627 Practice locations: Eagle Grove, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801596325. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Dec 19, 2003 in IA
Enrollment address
306 W Broadway St
Eagle Grove, IA 50533-1712

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
16D2281576Community Health Center of Eagle Grove306 W Broadway St, Eagle Grove, IA 50533Provider-performed microscopyMay 8, 2027

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
Renae Kruckenberg Individual Corporate DirectorCeo Mar 1, 2023 100%
Jana Woodruff Individual W-2 Managing EmployeeCredentialing Specialist Mar 1, 2023 100%

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Community Health Center of DaytonDayton, IA, CCN 161885 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 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 2

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

Practitioners & affiliated clinicians

Practitioners 12

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": "1677801600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1677801600000",
    "number": "1801596325",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "126 N 10TH ST",
            "city": "FORT DODGE",
            "state": "IA",
            "postal_code": "505013915",
            "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": "306 W BROADWAY ST",
            "city": "EAGLE GROVE",
            "state": "IA",
            "postal_code": "505331712",
            "telephone_number": "515-576-6500",
            "fax_number": "515-576-1951"
        }
    ],
    "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": "2023-03-03",
        "last_updated": "2023-03-03",
        "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 Eagle Grove",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Eagle Grove, IA

Sources for this page

Verify at the official NPI Registry.