MEDICARE: GREEN MANOR DIALYSIS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	1059202R	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467445601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN MANOR DIALYSIS CENTER LLC

Provider Business Mailing Address
First Line	:	30 WHITTIER WAY
Second Line	:
City	:	GHENT
State	:	NY
Zip	:	12075
Country	:	US
Telephone Number	:	518-828-0717
Fax Number	:	517-822-0776

Provider Business Practice Location Address
First Line	:	30 WHITTIER WAY
Second Line	:
City	:	GHENT
State	:	NY
Zip	:	12075
Country	:	US
Telephone Number	:	518-828-0717
Fax Number	:	517-822-0776

Authorized Official
Title or Position	:	CEO
Name	:	VINNY ANAND
Credential	:	MD
Telephone Number	:	518-828-0717

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	08/22/2020

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