Healthcare Provider Details

I. General information

NPI: 1275750606
Provider Name (Legal Business Name): C. WALLACE LILES, JR OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703J HIGHWAY 71 N
MENA AR
71953-4395
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:
Mailing address:
  • Phone: 479-394-4215
  • Fax:

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 JR.
Title or Position: DR
Credential: O.D.
Phone: 479-394-4215