Provider Demographics
NPI:1518951128
Name:SENIOR CARE SERVICE LLC
Entity Type:Organization
Organization Name:SENIOR CARE SERVICE LLC
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:P
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 1:565 S COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-6900
Practice Address - Country:US
Practice Address - Phone:970-812-0811
Practice Address - Fax:800-880-6549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2022-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO02542390000332B00000X
332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM73489Medicaid
WA9032087Medicaid
CO88103811Medicaid
ID805602500Medicaid
NH3085727Medicaid
NJ4996909Medicaid
MD6797008 00Medicaid
OH88103811Medicaid
MT0005603183Medicaid
PA0012521830002Medicaid
WA9032087Medicaid
ID805602500Medicaid
IL=========001Medicaid
NE=========00Medicaid
DE000983016Medicaid
OH0823765Medicaid
ID805602500Medicaid
VA9109951Medicaid
IL=========001Medicaid