Healthcare Provider Details

I. General information

NPI: 1811892185
Provider Name (Legal Business Name): KOUMANIS DIET HEALTH CLINIC OF MICHIGAN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2243 E 12 MILE RD
WARREN MI
48092-5644
US

IV. Provider business mailing address

2243 E 12 MILE RD
WARREN MI
48092-5644
US

V. Phone/Fax

Practice location:
  • Phone: 518-203-2593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DIMITRI J KOUMANIS
Title or Position: OWNER
Credential:
Phone: 518-203-2593