Healthcare Provider Details

I. General information

NPI: 1003022369
Provider Name (Legal Business Name): LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 15TH ST
PANAMA CITY FL
32405-5412
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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWIN R. AILES
Title or Position: EXECUTIVE DIRECTOR
Credential: LMFT
Phone: 850-522-8840