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General NPI Number Information
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NPI Number | 1730072075
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE MEDICAL CLINIC P.L.L.C
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Dates
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Enumeration Date | 06/03/2025
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Last Update Date | 10/10/2025
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Provider Practice Location Address
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Address Line | 416 N 1ST ST STE 2
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City | MONTEVIDEO
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State | MN
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Zip | 56265-1408
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Country | US
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Telephone | 320-226-5416
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 27
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City | MONTEVIDEO
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State | MN
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Zip | 56265-0027
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Country | US
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Telephone | 320-226-5416
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Fax |
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Authorized Official
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Title or Position | CLINIC OWNER
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Name | WYATT C. HAUGEN
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Credential | CWCA-BC, CSWS-BC
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Telephone | 320-226-5416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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