Healthcare Provider Details

I. General information

NPI: 1467378034
Provider Name (Legal Business Name): MR. GORDON MADDOX JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5686 BROADVIEW RD APT 2428
PARMA OH
44134-1647
US

IV. Provider business mailing address

5686 BROADVIEW RD APT 2428
PARMA OH
44134-1647
US

V. Phone/Fax

Practice location:
  • Phone: 216-406-1155
  • Fax:
Mailing address:
  • Phone: 216-406-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number1829089
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: