Healthcare Provider Details

I. General information

NPI: 1750461752
Provider Name (Legal Business Name): TREE TRAIL MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 TECH DR STE 460
NORCROSS GA
30093-6245
US

IV. Provider business mailing address

1250 TECH DR STE 460
NORCROSS GA
30093-6245
US

V. Phone/Fax

Practice location:
  • Phone: 770-638-7246
  • Fax: 770-806-0991
Mailing address:
  • Phone: 770-638-7246
  • Fax: 770-806-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR005852
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number038843
License Number StateGA

VIII. Authorized Official

Name: DR. KEVIN T LARSON
Title or Position: OWNER
Credential: D.C.
Phone: 770-638-7246