MEDICARE: RANDI BLACKMON LIKELY DC

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	111N00000X	Chiropractor	15153	TX

General Provider Information

NPI Number	:	1528701166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDI BLACKMON LIKELY DC

Provider Business Mailing Address
First Line	:	2578 MADISON AVE
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4566
Country	:	US
Telephone Number	:
Fax Number	:

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2022
Last Update Date	:	05/11/2022

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Directions to “ RANDI BLACKMON LIKELY DC” Practice Location

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