MEDICARE: MANTRO MOBILE IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0208X	Mobile Radiology Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V103481	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1285789370	OTHER		NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194000943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANTRO MOBILE IMAGING LLC

Provider Business Mailing Address
First Line	:	8778 S MARYLAND PKWY
Second Line	:	SUITE 105
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6704
Country	:	US
Telephone Number	:	702-896-0473
Fax Number	:	702-586-0528

Provider Business Practice Location Address
First Line	:	8778 S MARYLAND PKWY
Second Line	:	SUITE 105
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6704
Country	:	US
Telephone Number	:	702-896-0473
Fax Number	:	702-586-0528

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. KENNETH ROGER CHAPMAN JR.
Credential	:	RN
Telephone Number	:	702-896-0473

Provider Enumeration Date	:	10/12/2011
Last Update Date	:	01/30/2016

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8778 S MARYLAND PKWY , SUITE 105
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Directions to “MANTRO MOBILE IMAGING LLC ” Practice Location

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