MEDICARE: VITAS LABORATORY 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	:	1528507290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAS LABORATORY LLC

Provider Business Mailing Address
First Line	:	PO BOX 23189
Second Line	:
City	:	BARLING
State	:	AR
Zip	:	72923-0189
Country	:	US
Telephone Number	:	479-434-5643
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 FORT ST
Second Line	:	SUITE J
City	:	BARLING
State	:	AR
Zip	:	72923-2045
Country	:	US
Telephone Number	:	479-434-5643
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ CHIEF OF OPERATION
Name	:	CHRISTOPHER DOOLEY
Credential	:
Telephone Number	:	479-434-5643

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	05/11/2017

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