Provider Demographics
NPI:1508854571
Name:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC
Entity Type:Organization
Organization Name:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-522-4485
Mailing Address - Street 1:525 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5412
Mailing Address - Country:US
Mailing Address - Phone:850-522-4485
Mailing Address - Fax:850-914-6281
Practice Address - Street 1:525 EAST 15TH STREET
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-0000
Practice Address - Country:US
Practice Address - Phone:850-522-4485
Practice Address - Fax:850-914-6281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060296500Medicaid
FL99260OtherBLUE CROSS BLUE SHIELD
FL99260Medicare ID - Type Unspecified