1417954165 NPI number — ACTIVSTYLE, LLC

Table of content: (NPI 1417954165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417954165 NPI number — ACTIVSTYLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVSTYLE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417954165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 749061
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-9061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-651-6223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 WESTGATE DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-651-6223
Provider Business Practice Location Address Fax Number:
866-896-7171
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSALESI
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL, DIRECTOR/ OFFI
Authorized Official Telephone Number:
484-246-9499

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200106290A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54456 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807670400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9059163 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124008100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200219460 A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2227423 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1417954165 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 596546 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84532017 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0048074 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 183206 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101858880 0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5720001 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 014083000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013449 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1409928 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166866 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4582469 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004268844 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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