Healthcare Provider Details

I. General information

NPI: 1639754583
Provider Name (Legal Business Name): LIVING TREE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 N 200 E
LOGAN UT
84341-1913
US

IV. Provider business mailing address

1635 N 200 E
LOGAN UT
84341-1913
US

V. Phone/Fax

Practice location:
  • Phone: 435-565-6043
  • Fax: 435-215-4420
Mailing address:
  • Phone: 435-565-6043
  • Fax: 435-220-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRIS COLEMAN
Title or Position: COC
Credential:
Phone: 435-770-2131