MEDICARE: SNOWY MOUNTAIN MANAGEMENT PLLC

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	261QP2300X	Primary Care Clinic/Center	NC102817	NC

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	:	1306050588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SNOWY MOUNTAIN MANAGEMENT PLLC

Provider Business Mailing Address
First Line	:	2632 CAROLINA BEACH RD
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28412-1806
Country	:	US
Telephone Number	:	910-794-3939
Fax Number	:	910-794-3938

Provider Business Practice Location Address
First Line	:	2632 CAROLINA BEACH RD
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28412-1806
Country	:	US
Telephone Number	:	910-409-0922
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CHRIS DONOVIN
Credential	:	PA-C
Telephone Number	:	919-931-0490

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	09/25/2007

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