MEDICARE: BO WLMC 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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1073201638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BO WLMC LLC

Provider Business Mailing Address
First Line	:	6100 GREENLAND RD STE 301
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2626
Country	:	US
Telephone Number	:	904-467-4431
Fax Number	:	904-615-9966

Provider Business Practice Location Address
First Line	:	6100 GREENLAND RD STE 301
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2626
Country	:	US
Telephone Number	:	904-467-4431
Fax Number	:	904-615-9966

Authorized Official
Title or Position	:	OWNER
Name	:	IREN ORTIZ RAMIREZ
Credential	:	MD
Telephone Number	:	904-467-4431

Provider Enumeration Date	:	05/01/2023
Last Update Date	:	05/01/2023

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