Healthcare Provider Details

I. General information

NPI: 1962380337
Provider Name (Legal Business Name): MR. LATRELL RASHOD PETERSON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 HIGHLAND GREENS DR APT 215G
WEST CHESTER OH
45069-7664
US

IV. Provider business mailing address

6615 HIGHLAND GREENS DR APT 215G
WEST CHESTER OH
45069-7664
US

V. Phone/Fax

Practice location:
  • Phone: 734-304-3084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberVC597561
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberVC597561
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License NumberVC597561
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License NumberVC597561
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: