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General NPI Number Information
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NPI Number | 1649064338
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Entity Type | Individual
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Provider Name | WESLEY BAILES LDO
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Gender | Male
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Dates
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Enumeration Date | 04/07/2025
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Last Update Date | 04/07/2025
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Provider Practice Location Address
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Address Line | 5695 HIGHWAY 95 N
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86404-9646
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Country | US
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Telephone | 928-764-3755
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Fax |
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Provider Business Mailing Address
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Address Line | 3601 LOST DUTCHMAN DR UNIT A
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86406-6825
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Country | US
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Telephone | 928-486-1573
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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 | 156FX1800X
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Taxonomy Name | Optician
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License Number | LDO-003427
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License Number State | AZ
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