Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 EAST 15TH STREET
PANAMA CITY FL
32405-0000
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 850-522-4485
  • Fax: 850-257-7967
Mailing address:
  • Phone: 850-522-4485
  • Fax: 850-201-6024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWIN R AILES
Title or Position: CEO/PRESIDENT
Credential: LMFT
Phone: 850-522-4485