NPIMap

Organization Active NPI

C Wallace Liles Jr OD PA

Doing business as Liles Vision Clinic

  • Optometrist
  • De Queen, AR
National Provider Identifier
1316165178
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
Doing business as
Liles Vision Clinic
Practice address
404D E Collin Raye Dr
De Queen, AR 71832-4149
Phone
(870) 642-6900
Fax
(870) 642-4928
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 VI, O.D.NPI 1184620049
Title
Dr.
Phone
(870) 642-6900

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
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X AR2331 AR Primary

Addresses

Primary practice location

404D E Collin Raye Dr
De Queen, AR 71832-4149

Mailing address

404D E Collin Raye Dr
De Queen, AR 71832-4149
Phone (870) 642-6900

Other identifiers 1

IdentifierTypeStateIssuer
113655722MedicaidAR

Other names 1

  • LILES VISION CLINIC Doing business as

National Provider Directory

National Provider Directory

Locations

404 E Collin Raye Dr
De Queen, AR 71832

404 E Collin Raye Dr
#D
De Queen, AR 71832
Phone (870) 642-6900

Practitioners & affiliated clinicians

Practitioners 1

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": "1316165178",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "404D E COLLIN RAYE DR",
            "city": "DE QUEEN",
            "state": "AR",
            "postal_code": "718324149",
            "telephone_number": "870-642-6900",
            "fax_number": "870-642-4928"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "404D E COLLIN RAYE DR",
            "city": "DE QUEEN",
            "state": "AR",
            "postal_code": "718324149",
            "telephone_number": "870-642-6900",
            "fax_number": "870-642-4928"
        }
    ],
    "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": "870-642-6900",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "VI",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "AR",
            "license": "AR2331",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "113655722",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LILES VISION CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in De Queen, 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.