MEDICARE: REAL LIFE

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1487505814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAL LIFE

Provider Business Mailing Address
First Line	:	PO BOX 27372
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23261-7372
Country	:	US
Telephone Number	:	804-406-4111
Fax Number	:	804-294-2775

Provider Business Practice Location Address
First Line	:	1111 N 25TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5238
Country	:	US
Telephone Number	:	804-406-4111
Fax Number	:	804-294-2775

Authorized Official
Title or Position	:	MANAGER
Name	:	JASON HERZOG
Credential	:
Telephone Number	:	804-955-5246

Provider Enumeration Date	:	02/03/2026
Last Update Date	:	02/03/2026

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Directions to “REAL LIFE ” Practice Location

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