Provider Demographics
NPI:1730072075
Name:COUNTRYSIDE IV LOUNGE
Entity type:Organization
Organization Name:COUNTRYSIDE IV LOUNGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:C
Authorized Official - Last Name:HAUGEN
Authorized Official - Suffix:
Authorized Official - Credentials:CWCA-BC, CSWS-BC
Authorized Official - Phone:320-226-5416
Mailing Address - Street 1:214 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1413
Mailing Address - Country:US
Mailing Address - Phone:320-226-5416
Mailing Address - Fax:
Practice Address - Street 1:214 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1413
Practice Address - Country:US
Practice Address - Phone:320-226-5416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain