Healthcare Provider Details

I. General information

NPI: 1184620049
Provider Name (Legal Business Name): C. WALLACE LILES JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MORROW ST S
MENA AR
71953-2510
US

IV. Provider business mailing address

703J HIGHWAY 71 N
MENA AR
71953-4395
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 NumberAR2331
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: