MEDICARE: SUCCESS FOR LIFE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1881108512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUCCESS FOR LIFE INC

Provider Business Mailing Address
First Line	:	4627 N SHARON AMITY RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-4676
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4627 N SHARON AMITY RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-4676
Country	:	US
Telephone Number	:	704-299-1263
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	PERVIS NASH
Credential	:
Telephone Number	:	704-299-1263

Provider Enumeration Date	:	11/16/2017
Last Update Date	:	11/16/2017

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Directions to “SUCCESS FOR LIFE INC ” Practice Location

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