1760725105 NPI number — MANTRO MOBILE IMAGING LLC

Table of content: (NPI 1760725105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760725105 NPI number — MANTRO MOBILE IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANTRO MOBILE IMAGING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760725105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8778 S MARYLAND PKWY
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89123-6704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-942-1776
Provider Business Mailing Address Fax Number:
888-600-1534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6528 GREENLEAF AVE
Provider Second Line Business Practice Location Address:
STE 209
Provider Business Practice Location Address City Name:
WHITTIER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90601-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-592-0550
Provider Business Practice Location Address Fax Number:
888-600-1534
Provider Enumeration Date:
04/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CHAPMAN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
ROGER
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
888-592-0550

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GH589B . This is a "PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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