Provider Demographics
NPI:1750461752
Name:TREE TRAIL MEDICAL, LLC
Entity Type:Organization
Organization Name:TREE TRAIL MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-638-7246
Mailing Address - Street 1:1250 TECH DR STE 460
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-6245
Mailing Address - Country:US
Mailing Address - Phone:770-638-7246
Mailing Address - Fax:770-806-0991
Practice Address - Street 1:1250 TECH DR STE 460
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-6245
Practice Address - Country:US
Practice Address - Phone:770-638-7246
Practice Address - Fax:770-806-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005852111N00000X
GA038843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty