Organization
C WALLACE LILES III O D LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. C WALLACE LILES III OD (OWNER)
(479) 394-4215
Entity
Organization
Contact information
Practice address
404D E COLLIN RAYE DR, DE QUEEN, AR 71832-4149
(870) 642-6900
(870) 642-4928
Mailing address
404D E COLLIN RAYE DR, DE QUEEN, AR 71832-4149
(870) 642-6900
(870) 642-4928
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2331
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
181897722
—
AR
Enumeration date
10/29/2014
Last updated
10/29/2014
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