Healthcare Provider Details

I. General information

NPI: 1467445601
Provider Name (Legal Business Name): GREEN MANOR DIALYSIS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WHITTIER WAY
GHENT NY
12075
US

IV. Provider business mailing address

30 WHITTIER WAY
GHENT NY
12075
US

V. Phone/Fax

Practice location:
  • Phone: 518-828-0717
  • Fax: 517-822-0776
Mailing address:
  • Phone: 518-828-0717
  • Fax: 517-822-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1059202R
License Number StateNY

VIII. Authorized Official

Name: VINNY ANAND
Title or Position: CEO
Credential: MD
Phone: 518-828-0717