Healthcare Provider Details

I. General information

NPI: 1023233160
Provider Name (Legal Business Name): PETER E IVES II ATHLETIC TRAINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 YALE AVE
WALLINGFORD CT
06492-1838
US

IV. Provider business mailing address

718 BROAD ST UNIT B6
MERIDEN CT
06450-4371
US

V. Phone/Fax

Practice location:
  • Phone: 203-294-0449
  • Fax:
Mailing address:
  • Phone: 203-639-8556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001031
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: