Provider Demographics
NPI:1659636298
Name:ACTIVSTYLE, INC
Entity type:Organization
Organization Name:ACTIVSTYLE, INC
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 1:1055 WESTGATE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1451
Mailing Address - Country:US
Mailing Address - Phone:888-280-8632
Mailing Address - Fax:
Practice Address - Street 1:241 CHURCH ST
Practice Address - Street 2:SUITE G
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1548
Practice Address - Country:US
Practice Address - Phone:612-928-6822
Practice Address - Fax:866-896-7171
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVSTYLE HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-10
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI5720001Medicaid
CT004268844Medicaid
RI5720001Medicaid