Provider Demographics
NPI:1912896135
Name:COUNTRY MANOR CAMPUS LLC
Entity type:Organization
Organization Name:COUNTRY MANOR CAMPUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HARGUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-258-8983
Mailing Address - Street 1:520 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-1274
Mailing Address - Country:US
Mailing Address - Phone:320-253-1920
Mailing Address - Fax:
Practice Address - Street 1:520 1ST ST NE
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-1274
Practice Address - Country:US
Practice Address - Phone:320-253-1920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTRY MANOR CAMPUS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health