=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417815168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALIS MOLECULAR LABS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2026
-----------------------------------------------------
Last Update Date | 01/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 806 PIERCE DR
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31021-4532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-272-1666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 806 PIERCE DR
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31021-4532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-272-1666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. JOANNE GAST I
-----------------------------------------------------
Credential | ETC
-----------------------------------------------------
Telephone | 239-272-1666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------