Provider Demographics
NPI:1114542412
Name:DEFELICE, EUGENE VINCENT
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:VINCENT
Last Name:DEFELICE
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 1:2015 2ND AVE UNIT 2010
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-4022
Mailing Address - Country:US
Mailing Address - Phone:347-852-0067
Mailing Address - Fax:
Practice Address - Street 1:901 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2839
Practice Address - Country:US
Practice Address - Phone:206-470-3869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program