Provider Demographics
NPI:1467445601
Name:GREEN MANOR DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:GREEN MANOR DIALYSIS CENTER LLC
Other - Org Name:DBA COLUMBIA-GREENE DIALYSIS CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VINNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-828-0717
Mailing Address - Street 1:30 WHITTIER WAY
Mailing Address - Street 2:
Mailing Address - City:GHENT
Mailing Address - State:NY
Mailing Address - Zip Code:12075
Mailing Address - Country:US
Mailing Address - Phone:518-828-0717
Mailing Address - Fax:517-822-0776
Practice Address - Street 1:30 WHITTIER WAY
Practice Address - Street 2:
Practice Address - City:GHENT
Practice Address - State:NY
Practice Address - Zip Code:12075
Practice Address - Country:US
Practice Address - Phone:518-828-0717
Practice Address - Fax:517-822-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1059202R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01687094Medicaid
NY332562Medicare ID - Type Unspecified