ACTIVSTYLE, LLC

Provider Demographics

• NPI: 1417954165
• Name: ACTIVSTYLE, LLC
• Entity Type: Organization
• Organization Name: ACTIVSTYLE, LLC
• Authorized Official - Title/Position: AUTHORIZED OFFICIAL, DIRECTOR/ OFFI
• Authorized Official - First Name: WENDY
• Authorized Official - Last Name: RUSSALESI
• Authorized Official - Phone: 484-246-9499
• Mailing Address - Street 1: PO BOX 749061
• Mailing Address - City: LOS ANGELES
• Mailing Address - State: CA
• Mailing Address - Zip Code: 90074-9061
• Mailing Address - Country: US
• Mailing Address - Phone: 800-651-6223
• Practice Address - Street 1: 1055 WESTGATE DR STE 100
• Practice Address - City: SAINT PAUL
• Practice Address - State: MN
• Practice Address - Zip Code: 55114-1451
• Practice Address - Country: US
• Practice Address - Phone: 800-651-6223
• Practice Address - Fax: 866-896-7171
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: ADAPTHEALTH LLC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2005-07-07
• Last Update Date: 2023-10-04

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
No	332BP3500X	Suppliers	Durable Medical Equipment & Medical Supplies	Parenteral & Enteral Nutrition

Provider Identifiers

State	Identifier ID	ID Type	Issuer
OK	200106290A	Medicaid
ND	54456	Medicaid
ID	807670400	Medicaid
WA	9059163	Medicaid
WY	124008100	Medicaid
IN	200219460 A	Medicaid
OH	2227423	Medicaid
IA	1417954165	Medicaid
HI	596546	Medicaid
NM	84532017	Medicaid
MT	0048074	Medicaid
AZ	183206	Medicaid
PA	101858880 0002	Medicaid
RI	5720001	Medicaid
MD	014083000	Medicaid
VT	1013449	Medicaid
LA	1409928	Medicaid
AL	166866	Medicaid
TN	4582469	Medicaid
CT	004268844	Medicaid
VA	101373387	Medicaid
AK	1021830	Medicaid
MN	1417954165	Medicaid
CO	34951725	Medicaid
OH	2227423	Medicaid
TN	4582469	Medicaid
OH	2227423	Medicaid
MN	872217000	Medicaid