NPIMap

Organization Active NPI

Community Health Center of Fort Dodge, Inc.

  • Clinic Pharmacy
  • Fort Dodge, IA
National Provider Identifier
1881766400
Registry record updated Feb 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic PharmacyTaxonomy code 3336C0002X
License
1300 Issued in IA
Legal business name
COMMUNITY HEALTH CENTER OF FORT DODGE, INC.
Practice address
126 N 10TH St
Fort Dodge, IA 50501-3915
Phone
(515) 576-6500
Fax
(515) 576-1951
NPI assigned
Nov 15, 2006
Last updated
Feb 4, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 4, 2022

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic Pharmacy 3336C0002X 1300 IA Primary

Addresses

Primary practice location

126 N 10TH St
Fort Dodge, IA 50501-3915

Mailing address

126 N 10TH St
Fort Dodge, IA 50501-3915

Other identifiers 2

IdentifierTypeStateIssuer
1622869OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0490383MedicaidIA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20101116000211 IA Part A Provider - Federally Qualified Health Center (FQHC) 1557378627 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fort Dodge, IA
O20240425003578 IA Part B Supplier - Pharmacy 1557378627 Practice locations: Fort Dodge, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881766400. Details of each certification follow.

Federally qualified health center certification: CCN 161829

Legal name
COMMUNITY HEALTH CENTER OF FORT DODGE INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 27, 2006
Last certification
Apr 27, 2006
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 19, 2003 in IA
Enrollment address
126 N 10TH St
Fort Dodge, IA 50501-3915

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 1

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 5

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 Jan 1, 2013 100%
Operational/Managerial ControlCeo Jan 1, 2013
Becky Schulte Individual OtherBoard Member Mar 1, 2012
David Bowser Individual OtherBoard Member Mar 1, 2010
Dale Harlow Individual OtherBoard Member Mar 1, 2010
Kittie Webster Individual OtherBoard Member Mar 1, 2009

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.

NPI Registry JSON

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

{
    "created_epoch": "1163548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643932800000",
    "number": "1881766400",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "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"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTER OF FORT DODGE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-15",
        "last_updated": "2022-02-04",
        "certification_date": "2022-02-04",
        "status": "A",
        "authorized_official_last_name": "KRUCKENBERG",
        "authorized_official_first_name": "RENAE",
        "authorized_official_middle_name": "IRENE ELIZABETH",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "515-576-6500"
    },
    "taxonomies": [
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": "IA",
            "license": "1300",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
            "identifier": "1622869",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0490383",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Dodge, IA

Sources for this page

Verify at the official NPI Registry.