MEDICARE: MRS. KELLY WATERS SNOW RD, LDN

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	133V00000X	Registered Dietitian	401	SC

General Provider Information

NPI Number	:	1609635119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY WATERS SNOW RD, LDN

Provider Business Mailing Address
First Line	:	2841 OLD BRYAN DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5801
Country	:	US
Telephone Number	:	843-855-3009
Fax Number	:

Provider Business Practice Location Address
First Line	:	2841 OLD BRYAN DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5801
Country	:	US
Telephone Number	:	843-855-3009
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2024
Last Update Date	:	03/18/2024

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