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General NPI Number Information
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NPI Number | 1003044355
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Entity Type | Individual
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Provider Name | CLEMIT W LILES III O.D.
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Gender | Male
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Dates
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Enumeration Date | 06/25/2009
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Last Update Date | 11/28/2023
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Provider Practice Location Address
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Address Line | 2425 S ZERO ST
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City | FORT SMITH
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State | AR
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Zip | 72901-8663
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Country | US
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Telephone | 479-763-1230
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Fax | 479-777-4614
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Provider Business Mailing Address
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Address Line | 17569 FISHTRAP RD STE 30
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City | PROSPER
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State | TX
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Zip | 75078-5122
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Country | US
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Telephone | 469-715-0775
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2626
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License Number State | AR
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