Provider Demographics
NPI:1245406438
Name:FAMILY CARE CLINIC P.C.
Entity Type:Organization
Organization Name:FAMILY CARE CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NINO RENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:FORNASINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-622-3948
Mailing Address - Street 1:3985 STEVE REYNOLDS BLVD
Mailing Address - Street 2:BUILDING I
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093
Mailing Address - Country:US
Mailing Address - Phone:770-622-3948
Mailing Address - Fax:
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD
Practice Address - Street 2:BUILDING I
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093
Practice Address - Country:US
Practice Address - Phone:770-622-3948
Practice Address - Fax:770-622-4879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
GA048628261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000879755AMedicaid