Provider Demographics
NPI:1528781184
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:RN
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:434-989-8851
Mailing Address - Fax:
Practice Address - Street 1:2601 N STOCKTON HILL RD STE H-12
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4191
Practice Address - Country:US
Practice Address - Phone:702-896-0473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile