1588160089 NPI number — COMMUNITY HEALTH CENTER OF FORT DODGE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588160089 NPI number — COMMUNITY HEALTH CENTER OF FORT DODGE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY HEALTH CENTER OF FORT DODGE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588160089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 N 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DODGE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50501-3915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-576-6500
Provider Business Mailing Address Fax Number:
515-576-2021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 N FEDERAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASON CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50401-3214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-450-0601
Provider Business Practice Location Address Fax Number:
641-450-0612
Provider Enumeration Date:
04/03/2018

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  261QF0400X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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