Provider Demographics
NPI:1194000943
Name:MANTRO MOBILE IMAGING LLC
Entity Type:Organization
Organization Name:MANTRO MOBILE IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:RN
Authorized Official - Phone:702-896-0473
Mailing Address - Street 1:8778 S MARYLAND PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6704
Mailing Address - Country:US
Mailing Address - Phone:702-896-0473
Mailing Address - Fax:702-586-0528
Practice Address - Street 1:8778 S MARYLAND PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-6704
Practice Address - Country:US
Practice Address - Phone:702-896-0473
Practice Address - Fax:702-586-0528
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANTRO MOBILE IMAGING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-12
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
V103481OtherMEDICARE PTAN
1285789370OtherNPI
NV29X0009810Medicaid
V103481OtherMEDICARE PTAN