Provider Demographics
NPI:1760836126
Name:GREEN MANOR DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:GREEN MANOR DIALYSIS CENTER LLC
Other - Org Name:EAST GREENBUSH DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF DIALYSIS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOURNIER
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CNN
Authorized Official - Phone:518-828-0717
Mailing Address - Street 1:583 COLUMBIA TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-1602
Mailing Address - Country:US
Mailing Address - Phone:518-477-4370
Mailing Address - Fax:518-477-4319
Practice Address - Street 1:583 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061-1602
Practice Address - Country:US
Practice Address - Phone:518-477-4370
Practice Address - Fax:518-477-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1059202R261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01687094Medicaid
NY332562Medicare Oscar/Certification