Provider Demographics
NPI:1508253923
Name:GO HARD FOR LIFE INTERNATIONAL
Entity Type:Organization
Organization Name:GO HARD FOR LIFE INTERNATIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-850-9960
Mailing Address - Street 1:3211 BRAMER DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1603
Mailing Address - Country:US
Mailing Address - Phone:919-850-9960
Mailing Address - Fax:919-268-9660
Practice Address - Street 1:3211 BRAMER DRIVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1804
Practice Address - Country:US
Practice Address - Phone:919-850-9960
Practice Address - Fax:919-850-9961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21616101YA0400X, 101YM0800X, 103TE1100X, 104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty