Provider Demographics
NPI:1720401052
Name:HARTWELL, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:HARTWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6512 N DECATUR BLVD STE 130-114
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-1046
Mailing Address - Country:US
Mailing Address - Phone:702-830-2481
Mailing Address - Fax:702-664-0648
Practice Address - Street 1:5969 VIZZI CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-2858
Practice Address - Country:US
Practice Address - Phone:702-830-2481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health