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General NPI Number Information
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NPI Number | 1164488896
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Entity Type | Individual
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Provider Name | EUGENE RUSSELL FAILLACE D.C.
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Gender | Male
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Dates
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Enumeration Date | 04/21/2006
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Last Update Date | 12/10/2018
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Provider Practice Location Address
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Address Line | 3075 VETERANS MEMORIAL HWY STE 101
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City | RONKONKOMA
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State | NY
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Zip | 11779-7600
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Country | US
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Telephone | 631-708-5573
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Fax | 631-619-6543
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Provider Business Mailing Address
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Address Line | 64 SUYDAM LN
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City | BAYPORT
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State | NY
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Zip | 11705-2107
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Country | US
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Telephone | 631-472-2696
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | X007958
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License Number State | NY
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