Healthcare Provider Details

I. General information

NPI: 1912218207
Provider Name (Legal Business Name): MYO CARDIOVASCULAR CLINIC LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1596 SAN MATEO LN
SANTA FE NM
87505-3918
US

IV. Provider business mailing address

1596 SAN MATEO LN
SANTA FE NM
87505-3918
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-3077
  • Fax: 505-212-0229
Mailing address:
  • Phone: 505-670-3077
  • Fax: 505-212-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD2005-0713
License Number StateNM

VIII. Authorized Official

Name: DR. ARMIN FOGHI
Title or Position: MEDICAL DIRECTOR
Credential: MD,PHD
Phone: 505-220-5753