Provider Demographics
NPI:1164897930
Name:FORMATIVE CARE, INC.
Entity Type:Organization
Organization Name:FORMATIVE CARE, INC.
Other - Org Name:THE BELDEN HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-579-2735
Mailing Address - Street 1:606 HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4219
Mailing Address - Country:US
Mailing Address - Phone:707-579-2735
Mailing Address - Fax:707-579-4145
Practice Address - Street 1:606 HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4219
Practice Address - Country:US
Practice Address - Phone:707-579-2735
Practice Address - Fax:707-579-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496801719310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility