MEDICARE: VITAL LIFE LAB SERVICES LLC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1235080490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL LIFE LAB SERVICES LLC

Provider Business Mailing Address
First Line	:	2501 CHATHAM RD STE N
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:	309-309-3432
Fax Number	:

Provider Business Practice Location Address
First Line	:	2501 CHATHAM RD STE N
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:	309-309-3432
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	ASELA MOYA
Credential	:
Telephone Number	:	309-309-3432

Provider Enumeration Date	:	02/04/2026
Last Update Date	:	02/04/2026

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