Provider Demographics
NPI:1164488896
Name:FAILLACE, EUGENE RUSSELL (DC)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:RUSSELL
Last Name:FAILLACE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 SUYDAM LN
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-2107
Mailing Address - Country:US
Mailing Address - Phone:631-472-2696
Mailing Address - Fax:
Practice Address - Street 1:3075 VETERANS MEMORIAL HWY STE 101
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7600
Practice Address - Country:US
Practice Address - Phone:631-708-5573
Practice Address - Fax:631-619-6543
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007958111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX007958OtherNYS LICENSE
NYU58880Medicare UPIN
NYX007958OtherNYS LICENSE