NPIViewer - Provider NPI 1417954165

NPI:	1417954165
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:	DARRELL
Authorized Official - Middle Name:	DOUGLAS
Authorized Official - Last Name:	RAWLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:	612-895-7815
Mailing Address - Street 1:	PO BOX 749061
Mailing Address - Street 2:
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
Mailing Address - Fax:
Practice Address - Street 1:	1055 WESTGATE DR STE 100
Practice Address - Street 2:
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:	ACTIVSTYLE HOLDING COMPANY
Parent Organization TIN:	<UNAVAIL>
Enumeration Date:	2005-07-07
Last Update Date:	2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:

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

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