Provider Demographics
NPI:1275750606
Name:C. WALLACE LILES, JR OD PA
Entity Type:Organization
Organization Name:C. WALLACE LILES, JR OD PA
Other - Org Name:LILES VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:C.
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:LILES
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:479-394-4215
Mailing Address - Street 1:703J HIGHWAY 71 N
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4395
Mailing Address - Country:US
Mailing Address - Phone:479-394-4215
Mailing Address - Fax:
Practice Address - Street 1:703J HIGHWAY 71 N
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4395
Practice Address - Country:US
Practice Address - Phone:479-394-4215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103836722Medicaid
AR103836722Medicaid
ART20165Medicare UPIN
AR48113Medicare PIN