Provider Demographics
NPI:1811272669
Name:MANTRO MOBILE IMAGING LLC
Entity type:Organization
Organization Name:MANTRO MOBILE IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MISSIG
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:434-989-8851
Mailing Address - Street 1:8778 S MARYLAND PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6705
Mailing Address - Country:US
Mailing Address - Phone:888-592-0550
Mailing Address - Fax:888-600-1534
Practice Address - Street 1:6528 GREENLEAF AVE SUITE 209
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90601-4131
Practice Address - Country:US
Practice Address - Phone:888-592-0550
Practice Address - Fax:888-600-1534
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANTRO MOBILE IMAGING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-12
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGH589AOtherPTAN