Healthcare Provider Details

I. General information

NPI: 1295563385
Provider Name (Legal Business Name): TITAN STREAMSIDE OPERATOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 S EDGEWATER CIR
NAMPA ID
83686-6085
US

IV. Provider business mailing address

840 APOLLO ST STE 100
EL SEGUNDO CA
90245-4641
US

V. Phone/Fax

Practice location:
  • Phone: 208-442-0097
  • Fax:
Mailing address:
  • Phone: 310-725-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: REBECCA WONG
Title or Position: CFO
Credential:
Phone: 310-725-0120