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General NPI Number Information
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NPI Number | 1760836126
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Entity Type | Organization
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Legal Business Name | GREEN MANOR DIALYSIS CENTER LLC
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Dates
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Enumeration Date | 04/21/2016
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Last Update Date | 05/24/2016
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Provider Practice Location Address
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Address Line | 583 COLUMBIA TPKE
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City | EAST GREENBUSH
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State | NY
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Zip | 12061-1602
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Country | US
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Telephone | 518-477-4370
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Fax | 518-477-4319
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Provider Business Mailing Address
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Address Line | 583 COLUMBIA TPKE
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City | EAST GREENBUSH
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State | NY
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Zip | 12061-1602
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Country | US
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Telephone | 518-477-4370
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Fax | 518-477-4319
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Authorized Official
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Title or Position | DIRECTOR OF DIALYSIS SERVICES
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Name | EDWARD FOURNIER
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Credential | RN,CNN
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Telephone | 518-828-0717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | 1059202R
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License Number State | NY
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