MEDICARE: BACKED BY BLACKMON

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1306580584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACKED BY BLACKMON

Provider Business Mailing Address
First Line	:	17047 EL CAMINO REAL STE 140
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-2615
Country	:	US
Telephone Number	:	713-321-0506
Fax Number	:	713-383-6263

Provider Business Practice Location Address
First Line	:	17047 EL CAMINO REAL STE 140
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-2615
Country	:	US
Telephone Number	:	713-321-0506
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RANDI BLACKMON
Credential	:	DC
Telephone Number	:	713-855-2929

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	06/04/2026

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