1902194889 NPI number — ACTIVSTYLE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902194889 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:
1902194889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 W GERMANTOWN PIKE STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH MEETING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19462-1437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2615 E END BLVD S
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
MARSHALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75672-7425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-923-7010
Provider Business Practice Location Address Fax Number:
903-923-7011
Provider Enumeration Date:
07/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GRIGGS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
407-206-0040

Provider Taxonomy Codes

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

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

  • Identifier: 1409928 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203671716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 286522201 & 02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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