MEDICARE: LIFE MANAGEMENT CENTER OF NW FL, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	261QP2300X	Primary Care Clinic/Center
3	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	99260	OTHER	FL	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508854571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE MANAGEMENT CENTER OF NW FL, INC.

Provider Business Mailing Address
First Line	:	525 E 15TH ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-5412
Country	:	US
Telephone Number	:	850-522-4485
Fax Number	:	850-914-6281

Provider Business Practice Location Address
First Line	:	525 EAST 15TH STREET
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-0000
Country	:	US
Telephone Number	:	850-522-4485
Fax Number	:	850-257-7967

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	MR. EDWIN R AILES
Credential	:	LMFT
Telephone Number	:	850-522-4485

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	04/24/2025

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