Provider Demographics
NPI:1689087215
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 DAYTON
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:IRENE ELIZABETH
Authorized Official - Last Name:KRUCKENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-576-6500
Mailing Address - Street 1:24 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:IA
Mailing Address - Zip Code:50530-7698
Mailing Address - Country:US
Mailing Address - Phone:515-576-6500
Mailing Address - Fax:515-576-1951
Practice Address - Street 1:24 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:IA
Practice Address - Zip Code:50530
Practice Address - Country:US
Practice Address - Phone:515-547-2974
Practice Address - Fax:515-547-2976
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTH CENTER OF FORT DODGE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-11
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)