Provider Demographics
NPI:1154881464
Name:CCW LA JOLLA, LLC
Entity type:Organization
Organization Name:CCW LA JOLLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TOMEK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOSZYLKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-803-8443
Mailing Address - Street 1:233 S WACKER DR STE 8400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-6316
Mailing Address - Country:US
Mailing Address - Phone:312-803-8800
Mailing Address - Fax:
Practice Address - Street 1:8515 COSTA VERDE BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1130
Practice Address - Country:US
Practice Address - Phone:858-646-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility