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General NPI Number Information
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NPI Number | 1679422968
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Entity Type | Organization
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Legal Business Name | REVIVE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 01/28/2026
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Last Update Date | 01/28/2026
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Provider Practice Location Address
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Address Line | 4920 WATERLOO RD STE A
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City | ELLICOTT CITY
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State | MD
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Zip | 21043-6888
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Country | US
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Telephone | 443-438-0586
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Fax | 443-364-3039
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Provider Business Mailing Address
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Address Line | 10300B BALTIMORE NATIONAL PIKE
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City | ELLICOTT CITY
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State | MD
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Zip | 21042-2128
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Country | US
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Telephone | 443-438-0586
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Fax | 443-364-3039
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Authorized Official
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Title or Position | OWNER
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Name | RENUKA JAIN
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Credential | DPT
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Telephone | 781-266-6621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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