Healthcare Provider Details

I. General information

NPI: 1154121457
Provider Name (Legal Business Name): JACK HARTWELL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25381 RAILROAD CANYON RD STE 1101
LAKE ELSINORE CA
92532-2705
US

IV. Provider business mailing address

9900 INDIANA AVE STE 8
RIVERSIDE CA
92503-5498
US

V. Phone/Fax

Practice location:
  • Phone: 951-244-8404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number307740
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number307740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: