Healthcare Provider Details

I. General information

NPI: 1699581538
Provider Name (Legal Business Name): FORT-STAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 W 8TH ST
ERIE PA
16505-4935
US

IV. Provider business mailing address

1920 W 8TH ST
ERIE PA
16505-4935
US

V. Phone/Fax

Practice location:
  • Phone: 814-456-1097
  • Fax: 814-287-9375
Mailing address:
  • Phone: 814-456-1097
  • Fax: 814-287-9375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. VICKIE MARIE MCCLAY
Title or Position: OWNER
Credential: MPT
Phone: 814-602-8771