Healthcare Provider Details

I. General information

NPI: 1043689565
Provider Name (Legal Business Name): GO HARD FOR LIFE INTERNATIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4404 DEER KNOLL CT
RALEIGH NC
27603-8589
US

IV. Provider business mailing address

4404 DEER KNOLL CT
RALEIGH NC
27603-8589
US

V. Phone/Fax

Practice location:
  • Phone: 919-946-4712
  • Fax:
Mailing address:
  • Phone: 919-946-4712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9901279
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9901279
License Number StateNC

VIII. Authorized Official

Name: MELONIE MARSH
Title or Position: CO-OWNER
Credential:
Phone: 919-946-4712