Healthcare Provider Details

I. General information

NPI: 1730072075
Provider Name (Legal Business Name): COUNTRYSIDE MEDICAL CLINIC P.L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 10TH ST
CLARKFIELD MN
56223-1377
US

IV. Provider business mailing address

PO BOX 189
MONTEVIDEO MN
56265-0189
US

V. Phone/Fax

Practice location:
  • Phone: 320-321-2239
  • Fax:
Mailing address:
  • Phone: 320-269-1959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WYATT C. HAUGEN
Title or Position: CLINIC OWNER
Credential: CWCA-BC, CSWS-BC
Phone: 320-226-5416