Healthcare Provider Details

I. General information

NPI: 1669352738
Provider Name (Legal Business Name): REVIVA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4216 EVERGEEN LANE STE 125
ANNANDALE VA
22003-3456
US

IV. Provider business mailing address

5185 MACARTHUR BLVD NW # 713
WASHINGTON DC
20016-3341
US

V. Phone/Fax

Practice location:
  • Phone: 240-284-9501
  • Fax: 703-662-6165
Mailing address:
  • Phone: 301-893-4568
  • Fax: 240-427-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JIHO CHOI
Title or Position: OWNER
Credential: MD
Phone: 301-893-4568