Provider Demographics
NPI:1407847882
Name:ACTIVSTYLE LLC
Entity Type:Organization
Organization Name:ACTIVSTYLE LLC
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 1:220 W GERMANTOWN PIKE STE 250
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2139 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1018
Practice Address - Country:US
Practice Address - Phone:773-783-4600
Practice Address - Fax:773-783-8333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVSTYLE HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-03
Last Update Date:2023-01-24
Deactivation Date:2012-12-28
Deactivation Code:
Reactivation Date:2013-03-05
Provider Licenses
StateLicense IDTaxonomies
IL203000538332B00000X
IL203.001527332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid