| Organization Name: | GREEN MANOR DIALYSIS CENTER LLC |
| NPI Number: | 1760836126 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | EDWARD FOURNIER (DIRECTOR OF DIALYSIS SERVICES) |
| Mailing Address: | 583 Columbia Tpke East Greenbush |
| State: | NY US |
| Postal Code: | 120611602 |
| Phone Number: | 5184774370 |
| Fax Number: | 5184774319 |
| NPI Enumeration Date: | 04/21/2016 |
| NPI Last Update Date: | 05/24/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QE0700X |
| License Number: | 1059202R |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | End-Stage Renal Disease (ESRD) Treatment |
| Taxonomy Definition: | |