Provider Demographics
NPI:1588842033
Name:WILES & ASSOCIATES 6970 PA
Entity type:Organization
Organization Name:WILES & ASSOCIATES 6970 PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WILES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-887-0836
Mailing Address - Street 1:268 SAINT JOHNS GOLF DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1052
Mailing Address - Country:US
Mailing Address - Phone:904-887-0836
Mailing Address - Fax:
Practice Address - Street 1:6767 103RD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7135
Practice Address - Country:US
Practice Address - Phone:904-887-0836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078689600Medicaid
FLU13031Medicare UPIN
FL20115AMedicare PIN