Provider Demographics
NPI:1538943089
Name:VITALITY TRAVELING LABORATORY LLC
Entity type:Organization
Organization Name:VITALITY TRAVELING LABORATORY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RACHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PHLEBOTOMIST
Authorized Official - Phone:219-742-5233
Mailing Address - Street 1:7089 N CALDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-1032
Mailing Address - Country:US
Mailing Address - Phone:219-742-5233
Mailing Address - Fax:847-410-7256
Practice Address - Street 1:7089 N CALDWELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-1032
Practice Address - Country:US
Practice Address - Phone:219-742-5233
Practice Address - Fax:847-410-7256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-23
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory