Healthcare Provider Details

I. General information

NPI: 1124459151
Provider Name (Legal Business Name): LARRY L PETERSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S EDWIN C MOSES BLVD
DAYTON OH
45417-3424
US

IV. Provider business mailing address

1716 SALEM AVE
SPRINGFIELD OH
45505-4348
US

V. Phone/Fax

Practice location:
  • Phone: 937-734-8333
  • Fax:
Mailing address:
  • Phone: 937-536-7636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number378059
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number378059
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number378059
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN.378059
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: