Healthcare Provider Details

I. General information

NPI: 1407779721
Provider Name (Legal Business Name): COUNTRY MANOR CAMPUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 1ST ST NE
SARTELL MN
56377-1274
US

IV. Provider business mailing address

520 1ST ST NE
SARTELL MN
56377-1274
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-1920
  • Fax: 320-656-5922
Mailing address:
  • Phone: 320-253-1920
  • Fax: 320-656-5922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KEVIN HARGUTH
Title or Position: CFO
Credential:
Phone: 320-258-8983