=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730053299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GADDIS SPORTS NETWORK, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2025
-----------------------------------------------------
Last Update Date | 10/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14121 REXWOOD AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44105-6427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-502-9620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14121 REXWOOD AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44105-6427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | MR. LAMONTE GADDIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-502-9620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------