Healthcare Provider Details

I. General information

NPI: 1164886024
Provider Name (Legal Business Name): CHARLES STREET HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N CHARLES ST
BALTIMORE MD
21218-4300
US

IV. Provider business mailing address

8028 RITCHIE HWY SUITE 210B
PASADENA MD
21122-1075
US

V. Phone/Fax

Practice location:
  • Phone: 470-554-6300
  • Fax: 410-554-3919
Mailing address:
  • Phone: 410-766-1995
  • Fax: 470-761-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number30-018
License Number StateMD

VIII. Authorized Official

Name: MR. BRIAN FINGLASS
Title or Position: VP OF FINANCE
Credential: CFO
Phone: 410-766-1995