Provider Demographics
NPI:1184806143
Name:MANASSEH MEDICAL IMAGING, INC
Entity type:Organization
Organization Name:MANASSEH MEDICAL IMAGING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:RT(ARRT)
Authorized Official - Phone:806-239-0509
Mailing Address - Street 1:PO BOX 16856
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79490-6856
Mailing Address - Country:US
Mailing Address - Phone:806-771-1386
Mailing Address - Fax:
Practice Address - Street 1:4311 IRONTON AVE
Practice Address - Street 2:#2
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-3735
Practice Address - Country:US
Practice Address - Phone:806-239-0509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFTUVC9293D00000X
335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTUVC9Medicare PIN
TX459910Medicare PIN