Healthcare Provider Details

I. General information

NPI: 1558245076
Provider Name (Legal Business Name): REVIVE ROOTS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32145 ALVARADO NILES RD STE 202
UNION CITY CA
94587-2930
US

IV. Provider business mailing address

32145 ALVARADO NILES RD STE 202
UNION CITY CA
94587-2930
US

V. Phone/Fax

Practice location:
  • Phone: 510-961-0361
  • Fax:
Mailing address:
  • Phone: 510-961-0361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAILY KETANBHAI SHAH
Title or Position: PRESIDENT
Credential: MPT
Phone: 510-936-4392