Provider Demographics
NPI:1760630214
Name:COUNTRY MANOR CAMPUS LLC
Entity type:Organization
Organization Name:COUNTRY MANOR CAMPUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARGUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-258-8983
Mailing Address - Street 1:520 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-1274
Mailing Address - Country:US
Mailing Address - Phone:320-258-8972
Mailing Address - Fax:320-656-5922
Practice Address - Street 1:520 1ST ST NE
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-1274
Practice Address - Country:US
Practice Address - Phone:320-258-8972
Practice Address - Fax:320-656-5922
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE FOUNDATION FOR HEALTH CARE CONTINUUMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-08
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN153588343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)