Healthcare Provider Details

I. General information

NPI: 1871439281
Provider Name (Legal Business Name): CLUBHOUSE SENIOR ESTATE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 S FANN ST
ANAHEIM CA
92804-5648
US

IV. Provider business mailing address

1324 S FANN ST
ANAHEIM CA
92804-5648
US

V. Phone/Fax

Practice location:
  • Phone: 909-900-6064
  • Fax:
Mailing address:
  • Phone: 909-900-6064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GARY TADEO
Title or Position: CEO
Credential:
Phone: 909-900-6064