Provider Demographics
NPI:1649064338
Name:BAILES, WESLEY (LDO)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:BAILES
Suffix:
Gender:
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 LOST DUTCHMAN DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-6825
Mailing Address - Country:US
Mailing Address - Phone:928-486-1573
Mailing Address - Fax:
Practice Address - Street 1:5695 HIGHWAY 95 N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404-9646
Practice Address - Country:US
Practice Address - Phone:928-764-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLDO-003427156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician