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General NPI Number Information
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NPI Number | 1508854571
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Entity Type | Organization
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Legal Business Name | LIFE MANAGEMENT CENTER OF NW FL, INC.
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Dates
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Enumeration Date | 10/12/2005
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Last Update Date | 04/24/2025
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Provider Practice Location Address
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Address Line | 525 EAST 15TH STREET
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City | PANAMA CITY
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State | FL
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Zip | 32405-0000
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Country | US
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Telephone | 850-522-4485
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Fax | 850-257-7967
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Provider Business Mailing Address
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Address Line | 525 E 15TH ST
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City | PANAMA CITY
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State | FL
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Zip | 32405-5412
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Country | US
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Telephone | 850-522-4485
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Fax | 850-914-6281
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | MR. EDWIN R AILES
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Credential | LMFT
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Telephone | 850-522-4485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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