Provider Demographics
NPI:1467145151
Name:TITAN WILLOW OPERATOR LLC
Entity Type:Organization
Organization Name:TITAN WILLOW OPERATOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KASEFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-725-0120
Mailing Address - Street 1:THE WILLOWS
Mailing Address - Street 2:898 S MERIDIAN STREET
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-678-4411
Mailing Address - Fax:
Practice Address - Street 1:THE WILLOWS
Practice Address - Street 2:898 S MERIDIAN STREET
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-678-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility