Provider Demographics
NPI:1912991266
Name:GREEN MANOR DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:GREEN MANOR DIALYSIS CENTER LLC
Other - Org Name:NORTHERN HUDSON VALLEY DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO MEDICAL DIRECTOR
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:518-943-1404
Mailing Address - Street 1:159 JEFFERSON HTS
Mailing Address - Street 2:
Mailing Address - City:CATSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12414-1237
Mailing Address - Country:US
Mailing Address - Phone:518-943-1404
Mailing Address - Fax:518-943-2602
Practice Address - Street 1:159 JEFFERSON HTS
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1237
Practice Address - Country:US
Practice Address - Phone:518-943-1404
Practice Address - Fax:518-943-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2008-07-09
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
NY332641Medicare ID - Type Unspecified