MEDICARE: JACK HARTWELL DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	307740	CA
2	225100000X	Physical Therapist	307740	CA

General Provider Information

NPI Number	:	1154121457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK HARTWELL DPT

Provider Business Mailing Address
First Line	:	9900 INDIANA AVE STE 8
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92503-5498
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25381 RAILROAD CANYON RD STE 1101
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92532-2705
Country	:	US
Telephone Number	:	951-244-8404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2025
Last Update Date	:	05/28/2025

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