Healthcare Provider Details

I. General information

NPI: 1336810472
Provider Name (Legal Business Name): VITAL LAB SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 PLYMOUTH AVE STE 127
SAINT LOUIS MO
63133-1940
US

IV. Provider business mailing address

6439 PLYMOUTH AVE STE 127
SAINT LOUIS MO
63133-1940
US

V. Phone/Fax

Practice location:
  • Phone: 636-465-3004
  • Fax: 314-833-3170
Mailing address:
  • Phone: 636-465-3004
  • Fax: 314-833-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SHAUNICE SHELTON
Title or Position: DIRECTOR
Credential: RN
Phone: 636-465-3004