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General NPI Number Information
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NPI Number | 1275750606
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Entity Type | Organization
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Legal Business Name | C. WALLACE LILES, JR OD PA
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 06/17/2009
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Provider Practice Location Address
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Address Line | 703J HIGHWAY 71 N
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City | MENA
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State | AR
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Zip | 71953-4395
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Country | US
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Telephone | 479-394-4215
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Fax |
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Provider Business Mailing Address
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Address Line | 703J HIGHWAY 71 N
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City | MENA
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State | AR
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Zip | 71953-4395
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Country | US
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Telephone | 479-394-4215
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Fax |
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Authorized Official
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Title or Position | DR
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Name | DR. C. WALLACE LILES JR.
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Credential | O.D.
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Telephone | 479-394-4215
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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 | AR2331
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License Number State | AR
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