Provider Demographics
NPI:1285789370
Name:MANTRO MOBILE IMAGING LLC
Entity type:Organization
Organization Name:MANTRO MOBILE IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MISSIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-989-8851
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2000422.3202471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV29X0009810Medicaid
NV29X0009810Medicaid