Provider Demographics
NPI:1376948687
Name:C WALLACE LILES III O D LLC
Entity Type:Organization
Organization Name:C WALLACE LILES III O D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:LILES
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:479-394-4215
Mailing Address - Street 1:404D E COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-4149
Mailing Address - Country:US
Mailing Address - Phone:870-642-6900
Mailing Address - Fax:870-642-4928
Practice Address - Street 1:404D E COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-4149
Practice Address - Country:US
Practice Address - Phone:870-642-6900
Practice Address - Fax:870-642-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181897722Medicaid
AR181897722Medicaid
AR5H901G256Medicare PIN