Healthcare Provider Details

I. General information

NPI: 1568384345
Provider Name (Legal Business Name): EUGEANA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LYMAN CT
LONGS SC
29568-7663
US

IV. Provider business mailing address

2195 LIVINGSTON LN
LONGS SC
29568-7412
US

V. Phone/Fax

Practice location:
  • Phone: 803-543-3288
  • Fax:
Mailing address:
  • Phone: 804-643-3288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13233
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: