Provider Demographics
NPI:1508030347
Name:COMMUNITY HEALTH CENTER OF FORT DODGE INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTER OF FORT DODGE INC.
Other - Org Name:COMMUNITY HEALTH CENTER OF FORT DODGE DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:515-576-6500
Mailing Address - Street 1:126 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3915
Mailing Address - Country:US
Mailing Address - Phone:515-576-6500
Mailing Address - Fax:515-576-1951
Practice Address - Street 1:330 AVENUE M
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5739
Practice Address - Country:US
Practice Address - Phone:515-576-6500
Practice Address - Fax:515-576-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0490383Medicaid