Provider Demographics
NPI:1639754583
Name:LIVING TREE MEDICAL GROUP
Entity Type:Organization
Organization Name:LIVING TREE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COC
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-770-2131
Mailing Address - Street 1:169 N GATEWAY DR STE 170
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9855
Mailing Address - Country:US
Mailing Address - Phone:435-565-6043
Mailing Address - Fax:435-215-4420
Practice Address - Street 1:169 N GATEWAY DR STE 170
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9855
Practice Address - Country:US
Practice Address - Phone:435-565-6043
Practice Address - Fax:435-215-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty