Provider Demographics
NPI:1285819920
Name:CHAMPLAIN VALLEY BRACE AND LIMB, L.L.C.
Entity Type:Organization
Organization Name:CHAMPLAIN VALLEY BRACE AND LIMB, L.L.C.
Other - Org Name:ACTIVSTYLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-206-0040
Mailing Address - Street 1:1701 BROADWAY ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2638
Mailing Address - Country:US
Mailing Address - Phone:800-651-6223
Mailing Address - Fax:866-896-7171
Practice Address - Street 1:528 ESSEX RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7555
Practice Address - Country:US
Practice Address - Phone:518-907-0225
Practice Address - Fax:518-561-5335
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVSTYLE HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-31
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1013711Medicaid
NY5301410001Medicare NSC