MEDICARE: COUNTRY MANOR CAMPUS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1942763313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY MANOR CAMPUS LLC

Provider Business Mailing Address
First Line	:	520 1ST ST NE
Second Line	:
City	:	SARTELL
State	:	MN
Zip	:	56377-1274
Country	:	US
Telephone Number	:	320-258-8983
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 LANIGAN WAY SW
Second Line	:
City	:	SAINT JOSEPH
State	:	MN
Zip	:	56374-4732
Country	:	US
Telephone Number	:	320-253-3343
Fax Number	:	320-240-0244

Authorized Official
Title or Position	:	C.F.O.
Name	:	KEVIN HARGUTH
Credential	:
Telephone Number	:	320-258-8983

Provider Enumeration Date	:	04/11/2019
Last Update Date	:	06/30/2021

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