Provider Demographics
NPI:1316977515
Name:LIFE MANAGEMENT OF NW FL, INC.
Entity type:Organization
Organization Name:LIFE MANAGEMENT OF NW FL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-522-4485
Mailing Address - Street 1:525 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5412
Mailing Address - Country:US
Mailing Address - Phone:850-522-4480
Mailing Address - Fax:850-914-6281
Practice Address - Street 1:311 WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1845
Practice Address - Country:US
Practice Address - Phone:850-522-4480
Practice Address - Fax:850-914-6281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060296530Medicaid
FL99260DMedicare ID - Type Unspecified