Provider Demographics
NPI:1558245076
Name:REVIVE ROOTS PHYSICAL THERAPY
Entity type:Organization
Organization Name:REVIVE ROOTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAILY
Authorized Official - Middle Name:KETANBHAI
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:510-936-4392
Mailing Address - Street 1:32145 ALVARADO NILES RD STE 202
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-2930
Mailing Address - Country:US
Mailing Address - Phone:510-961-0361
Mailing Address - Fax:
Practice Address - Street 1:32145 ALVARADO NILES RD STE 202
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-2930
Practice Address - Country:US
Practice Address - Phone:510-961-0361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy