MEDICARE: GO HARD FOR LIFE INTERNATIONAL

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	21616	NC
2	103TE1100X	Exercise & Sports Psychologist	21616	NC
3	104100000X	Social Worker	21616	NC
4	106H00000X	Marriage & Family Therapist	21616	NC
5	101YM0800X	Mental Health Counselor	21616	NC

General Provider Information

NPI Number	:	1508253923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GO HARD FOR LIFE INTERNATIONAL

Provider Business Mailing Address
First Line	:	3211 BRAMER DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-1603
Country	:	US
Telephone Number	:	919-850-9960
Fax Number	:	919-268-9660

Provider Business Practice Location Address
First Line	:	3211 BRAMER DRIVE
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-1804
Country	:	US
Telephone Number	:	919-850-9960
Fax Number	:	919-850-9961

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JERRY WILLIAM WILEY
Credential	:	M.D.
Telephone Number	:	919-850-9960

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	05/10/2016

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Directions to “GO HARD FOR LIFE INTERNATIONAL ” Practice Location

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