MEDICARE: VITALITY TRAVELING 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	:	1538943089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY TRAVELING LABORATORY LLC

Provider Business Mailing Address
First Line	:	1 E ERIE ST STE 525-4357
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2740
Country	:	US
Telephone Number	:	773-226-2149
Fax Number	:	219-803-2124

Provider Business Practice Location Address
First Line	:	1 E ERIE ST STE 525-4357
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2740
Country	:	US
Telephone Number	:	773-226-2149
Fax Number	:	219-803-2124

Authorized Official
Title or Position	:	PHLEBOTOMIST, OWNER
Name	:	RACHELE' JACQUES
Credential	:	M.A, PHLEBOTOMIST
Telephone Number	:	219-742-5233

Provider Enumeration Date	:	08/23/2023
Last Update Date	:	06/17/2025

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