Healthcare Provider Details

I. General information

NPI: 1043126568
Provider Name (Legal Business Name): JACK KOSTA DIMEFSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 HAMPTON CIR
ROCHESTER HILLS MI
48307-4103
US

IV. Provider business mailing address

141 HAMPTON CIR
ROCHESTER HILLS MI
48307-4103
US

V. Phone/Fax

Practice location:
  • Phone: 248-853-7555
  • Fax: 248-853-7556
Mailing address:
  • Phone: 248-853-7555
  • Fax: 248-853-7556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501304731
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: