Provider Demographics
NPI:1508641390
Name:DAVIS, EUGENIA L
Entity Type:Individual
Prefix:MRS
First Name:EUGENIA
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:EUGENIA
Other - Middle Name:L
Other - Last Name:HOLBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSED BARBER
Mailing Address - Street 1:4719 QUAIL LAKES DR STE G
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5267
Mailing Address - Country:US
Mailing Address - Phone:209-353-9140
Mailing Address - Fax:209-268-7647
Practice Address - Street 1:8803 FOX CREEK DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-1783
Practice Address - Country:US
Practice Address - Phone:209-353-9140
Practice Address - Fax:209-298-7647
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB106161335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier