Basic Information
| Provider Information | |||||||||
| NPI: | 1508854571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224485 | ||||||||
| FaxNumber: | 8509146281 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 EAST 15TH STREET | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324050000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224485 | ||||||||
| FaxNumber: | 8509146281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | AILES | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8505224485 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 99260 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 060296500 | 05 | FL | MEDICAID |