MEDICARE: BOATOX LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1770441248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOATOX LLC

Provider Business Mailing Address
First Line	:	24898 ROUTE W40
Second Line	:
City	:	BONAPARTE
State	:	IA
Zip	:	52620-8142
Country	:	US
Telephone Number	:	903-571-3844
Fax Number	:	855-343-5763

Provider Business Practice Location Address
First Line	:	113 W JACKSON ST STE 1A
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-2401
Country	:	US
Telephone Number	:	601-863-9663
Fax Number	:	855-343-5763

Authorized Official
Title or Position	:	REVENUE CYCLE ADMIN
Name	:	TERESA GREEN
Credential	:
Telephone Number	:	903-571-3844

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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Directions to “BOATOX LLC ” Practice Location

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