Healthcare Provider Details

I. General information

NPI: 1316165178
Provider Name (Legal Business Name): C WALLACE LILES JR OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404D E COLLIN RAYE DR
DE QUEEN AR
71832-4149
US

IV. Provider business mailing address

404D E COLLIN RAYE DR
DE QUEEN AR
71832-4149
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-6900
  • Fax: 870-642-4928
Mailing address:
  • Phone: 870-642-6900
  • Fax: 870-642-4928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAR2331
License Number StateAR

VIII. Authorized Official

Name: DR. C. WALLACE LILES VI
Title or Position: DR.
Credential: O.D.
Phone: 870-642-6900