Healthcare Provider Details

I. General information

NPI: 1760836126
Provider Name (Legal Business Name): GREEN MANOR DIALYSIS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

583 COLUMBIA TPKE
EAST GREENBUSH NY
12061-1602
US

IV. Provider business mailing address

583 COLUMBIA TPKE
EAST GREENBUSH NY
12061-1602
US

V. Phone/Fax

Practice location:
  • Phone: 518-477-4370
  • Fax: 518-477-4319
Mailing address:
  • Phone: 518-477-4370
  • Fax: 518-477-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number1059202R
License Number StateNY

VIII. Authorized Official

Name: EDWARD FOURNIER
Title or Position: DIRECTOR OF DIALYSIS SERVICES
Credential: RN,CNN
Phone: 518-828-0717