Provider Demographics
NPI:1407173487
Name:ACTIVSTYLE, INC
Entity Type:Organization
Organization Name:ACTIVSTYLE, INC
Other - Org Name:
Other - Org Type:
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 1:3500 LAKESIDE CT
Practice Address - Street 2:SUITE 200
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4829
Practice Address - Country:US
Practice Address - Phone:612-928-6826
Practice Address - Fax:866-301-2167
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVSTYLE HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-29
Last Update Date:2021-04-21
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
NV1407173487Medicaid
NV1265720003Medicare NSC