Healthcare Provider Details

I. General information

NPI: 1710912886
Provider Name (Legal Business Name): LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E BYRD AVE
BONIFAY FL
32425-3006
US

IV. Provider business mailing address

525 E 15TH ST
PANAMA CITY FL
32405-5412
US

V. Phone/Fax

Practice location:
  • Phone: 850-522-4480
  • Fax: 850-914-6281
Mailing address:
  • Phone: 850-522-4480
  • Fax: 850-914-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWIN AILES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 850-522-4480