Healthcare Provider Details

I. General information

NPI: 1750100558
Provider Name (Legal Business Name): EUGENE RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 MISSION AVE STE 230
OCEANSIDE CA
92058-7110
US

IV. Provider business mailing address

1701 MISSION AVE STE 230
OCEANSIDE CA
92058-7110
US

V. Phone/Fax

Practice location:
  • Phone: 760-721-3535
  • Fax:
Mailing address:
  • Phone: 818-268-6567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number21404
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: