=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730506494
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE ENHANCEMENT SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2014
-----------------------------------------------------
Last Update Date | 03/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8200 CARMEL AVE NE STE. 102
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87122-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-892-0402
-----------------------------------------------------
Fax | 505-892-5544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 GRANDE BLVD SE STE. C & D
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-1799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-892-0402
-----------------------------------------------------
Fax | 505-892-5544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CARDIOLOGIST
-----------------------------------------------------
Name | DR. ARMIN FOGHI
-----------------------------------------------------
Credential | M.D. PH.D
-----------------------------------------------------
Telephone | 505-892-0402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD2005-0713
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------