Provider Demographics
NPI:1457199945
Name:TITAN CONGLOMERATE LLC
Entity type:Organization
Organization Name:TITAN CONGLOMERATE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEMONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-922-0708
Mailing Address - Street 1:12309 W CAMBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5575
Mailing Address - Country:US
Mailing Address - Phone:213-922-0708
Mailing Address - Fax:
Practice Address - Street 1:12309 W CAMBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5575
Practice Address - Country:US
Practice Address - Phone:213-922-0708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health