Healthcare Provider Details

I. General information

NPI: 1386680809
Provider Name (Legal Business Name): JESSE LEE DIMICK PTA, LATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 REDLANDS RD
WEST ROXBURY MA
02132-1506
US

IV. Provider business mailing address

43 REDLANDS RD
WEST ROXBURY MA
02132-1506
US

V. Phone/Fax

Practice location:
  • Phone: 617-892-2749
  • Fax:
Mailing address:
  • Phone: 617-892-2749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1708
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: