C Wallace Liles III O D LLC
Organization Active NPI Optometrist · Mena, AR
NPI 1134524770 · NPPES record last updated Oct 24, 2014
Key facts
- NPI
- 1134524770
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- License
- 2331 (AR)
- Legal business name
- C WALLACE LILES III O D LLC
- Practice address
- 703 Highway 71 N Ste J
Mena, AR 71953-4341 - Phone
- (479) 394-4215
- Fax
- (479) 394-3455
- NPI assigned
- Oct 24, 2014
- Organization subpart
- No
Authorized official
- Name
- Dr. C Wallace Liles III, OD
- Title
- Owner
- Phone
- (479) 394-4215
National Provider Directory
Locations
2425 S Zero St
Fort Smith, AR 72901
Phone (479) 646-4983
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | 2331 | AR | Yes |
Addresses
Primary practice location
703 Highway 71 N Ste J
Mena, AR 71953-4341
Mailing address
703 Highway 71 N Ste J
Mena, AR 71953-4341
Phone (479) 394-4215
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 181897722 | Medicaid | AR |
Other providers in Mena, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 24, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.