1730072075 NPI number — COUNTRYSIDE MEDICAL CLINIC P.L.L.C

Table of content: (NPI 1730072075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730072075 NPI number — COUNTRYSIDE MEDICAL CLINIC P.L.L.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRYSIDE MEDICAL CLINIC P.L.L.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730072075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTEVIDEO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56265-0027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-226-5416
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 N 1ST ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEVIDEO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56265-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-226-5416
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2025

Additional Information

Authorized Official

Authorized Official Last Name:
HAUGEN
Authorized Official First Name:
WYATT
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
CLINIC OWNER
Authorized Official Telephone Number:
320-226-5416

Provider Taxonomy Codes

  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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