C Wallace Liles III O D LLC

Primary specialty

OptometristTaxonomy code 152W00000X

License

2331 Issued in AR

Legal business name

C WALLACE LILES III O D LLC

Practice address

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

Phone

(870) 642-6900

Fax

(870) 642-4928

NPI assigned

Oct 29, 2014

Last updated

Oct 29, 2014By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. C Wallace Liles III, OD

Title

Owner

Phone

(479) 394-4215

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1414540800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1414540800000",
    "number": "1376948687",
    "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 III O D LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-10-29",
        "last_updated": "2014-10-29",
        "status": "A",
        "authorized_official_last_name": "LILES",
        "authorized_official_first_name": "C",
        "authorized_official_middle_name": "WALLACE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "479-394-4215",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "III",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "AR",
            "license": "2331",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "181897722",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brookewood Limited Partnership (Brookewood Nursing & Rehab)
• Inja Cristal Brown, APRN
• Christie Bui, D.D.S.
• Italia Bustamante-Quintana, LMSW
• Alan Byrd
• C Wallace Liles Jr OD PA (Liles Vision Clinic)
• Ashley Caldwell, MS, CCC-SLP
• Jenna Christen Campbell, APN
• Megan Elaine Carter
• Laken Cassady, RN

• Optometrist in De Queen, AR
• Providers in De Queen, AR by specialty
• Optometrist in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2014; 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.