=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487505814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REAL LIFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2026
-----------------------------------------------------
Last Update Date | 02/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 N 25TH ST
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23223-5238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-406-4111
-----------------------------------------------------
Fax | 804-294-2775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 27372
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23261-7372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-406-4111
-----------------------------------------------------
Fax | 804-294-2775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JASON HERZOG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-955-5246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------