NPIMap

Organization Active NPI

C Wallace Liles Jr OD PA

  • Optometrist
  • Waldron, AR
National Provider Identifier
1043438807
Registry record updated Sep 1, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
AR2331 Issued in AR
Legal business name
C WALLACE LILES JR OD PA
Practice address
72 W 2ND St
Waldron, AR 72958-7085
Phone
(479) 637-5598
Fax
(479) 637-1195
NPI assigned
Apr 24, 2007
Last updated
Sep 1, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 1, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. C. Wallace Liles Jr., O.D.NPI 1184620049
Title
Dr.
Phone
(479) 637-5598

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X AR2331 AR Primary

Addresses

Primary practice location

72 W 2ND St
Waldron, AR 72958-7085

Mailing address

72 W 2ND St
Waldron, AR 72958-7085
Phone (479) 637-5598

Other identifiers 1

IdentifierTypeStateIssuer
125850722MedicaidAR

Other names 1

  • Liles Vision Clinic Former legal business name

National Provider Directory

National Provider Directory

Locations

72 W 2nd St
Waldron, AR 72958
Phone (479) 637-0914

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177372800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1251763200000",
    "number": "1043438807",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "72 W 2ND ST",
            "city": "WALDRON",
            "state": "AR",
            "postal_code": "729587085",
            "telephone_number": "479-637-5598",
            "fax_number": "479-637-1195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "72 W 2ND ST",
            "city": "WALDRON",
            "state": "AR",
            "postal_code": "729587085",
            "telephone_number": "479-637-5598",
            "fax_number": "479-637-1195"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "C WALLACE LILES JR OD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-24",
        "last_updated": "2009-09-01",
        "status": "A",
        "authorized_official_last_name": "LILES",
        "authorized_official_first_name": "C.",
        "authorized_official_middle_name": "WALLACE",
        "authorized_official_title_or_position": "DR.",
        "authorized_official_telephone_number": "479-637-5598",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "AR",
            "license": "AR2331",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "125850722",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Liles Vision Clinic",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Waldron, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.