Healthcare Provider Details

I. General information

NPI: 1487024758
Provider Name (Legal Business Name): MYO CARDIOVASCULAR CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 GRANDE BLVD SE
RIO RANCHO NM
87124-1726
US

IV. Provider business mailing address

1790 GRANDE BLVD SE
RIO RANCHO NM
87124-1726
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-0402
  • Fax: 505-892-5544
Mailing address:
  • Phone: 505-892-0402
  • Fax: 505-892-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD2005-0713
License Number StateNM

VIII. Authorized Official

Name: DR. ARMIN FOGHI
Title or Position: MD
Credential: MD
Phone: 505-892-0402