Healthcare Provider Details

I. General information

NPI: 1134524770
Provider Name (Legal Business Name): C WALLACE LILES III O D LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 HIGHWAY 71 N STE J
MENA AR
71953-4341
US

IV. Provider business mailing address

703 HIGHWAY 71 N STE J
MENA AR
71953-4341
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-4215
  • Fax: 479-394-3455
Mailing address:
  • Phone: 479-394-4215
  • Fax: 479-394-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2331
License Number StateAR

VIII. Authorized Official

Name: DR. C WALLACE LILES III
Title or Position: OWNER
Credential: OD
Phone: 479-394-4215