Provider Demographics
NPI:1306715230
Name:GRANT, COLONEL EUGENE
Entity type:Individual
Prefix:
First Name:COLONEL
Middle Name:EUGENE
Last Name:GRANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2173 EDEN TER APT 310
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-2878
Mailing Address - Country:US
Mailing Address - Phone:704-701-4024
Mailing Address - Fax:704-701-4024
Practice Address - Street 1:2173 EDEN TER APT 310
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-2878
Practice Address - Country:US
Practice Address - Phone:704-701-4024
Practice Address - Fax:704-701-4024
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-30
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC445BKZ172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver