=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528701166
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDI BLACKMON LIKELY DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2022
-----------------------------------------------------
Last Update Date | 05/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17047 EL CAMINO REAL STE 140
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77058-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-321-0506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2578 MADISON AVE
-----------------------------------------------------
City | LEAGUE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77573-4566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 15153
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------