Basic Information
| Provider Information | |||||||||
| NPI: | 1023233160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVES | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | ATHLETIC TRAINER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 BROAD ST | ||||||||
| Address2: | UNIT B6 | ||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064504371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036398556 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 YALE AVE | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064921838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032940449 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 000208 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.