Provider Demographics
NPI:1659301877
Name:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC
Entity Type:Organization
Organization Name:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC
Other - Org Name:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-522-4480
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:850-522-4480
Mailing Address - Fax:850-914-6281
Practice Address - Street 1:16869 NE PEAR ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1774
Practice Address - Country:US
Practice Address - Phone:850-522-4480
Practice Address - Fax:850-914-6281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060296538Medicaid