Healthcare Provider Details

I. General information

NPI: 1972574507
Provider Name (Legal Business Name): CCW LA JOLLA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4171 LAS PALMAS SQ
SAN DIEGO CA
92122-6627
US

IV. Provider business mailing address

233 S WACKER DR STE 8400
CHICAGO IL
60606-6316
US

V. Phone/Fax

Practice location:
  • Phone: 858-646-3400
  • Fax: 858-646-0064
Mailing address:
  • Phone: 312-803-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number080000751
License Number StateCA

VIII. Authorized Official

Name: TOMEK J KOSZYLKO
Title or Position: COUNSEL
Credential:
Phone: 312-803-8443