Individual
C. WALLACE LILES JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
208 MORROW ST S, MENA, AR 71953-2510
(479) 394-4215
(479) 394-3455
Mailing address
703J HIGHWAY 71 N, MENA, AR 71953-4395
(479) 394-4215
(479) 394-3455
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
AR2331
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
103836722
—
AR
Enumeration date
06/24/2005
Last updated
06/03/2019
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