Healthcare Provider Details

I. General information

NPI: 1740194554
Provider Name (Legal Business Name): COLORADO CARE HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N COLORADO ST
ANAHEIM CA
92801-4839
US

IV. Provider business mailing address

436 N COLORADO ST
ANAHEIM CA
92801-4839
US

V. Phone/Fax

Practice location:
  • Phone: 714-600-3407
  • Fax:
Mailing address:
  • Phone: 714-600-3407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: JILMARK REALIS
Title or Position: LICENSEE
Credential:
Phone: 714-600-3407