NPIMap

Organization Active NPI

Divine Medical Wellness Center Inc

  • General Practice Physician
  • Fresno, CA
National Provider Identifier
1972920098
Registry record updated Mar 26, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
DIVINE MEDICAL WELLNESS CENTER INC
Practice address
5150 N 6TH St Ste 100
Fresno, CA 93710-7505
Phone
(559) 222-5362
NPI assigned
Mar 26, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 26, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Randall Lynn Roulund, DCNPI 1205866035
Title
President
Phone
(559) 222-5362

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
ChiropractorGroup: 193200000X MULTI-SPECIALTY GROUP 111N00000X
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X Primary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

Primary practice location

5150 N 6TH St Ste 100
Fresno, CA 93710-7505

Mailing address

5150 N 6TH St Ste 100
Fresno, CA 93710-7505
Phone (559) 222-5362

Other names 1

  • Divine Medical Wellness Center Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20180626002778 CA Part B Supplier - Clinic/Group Practice 2264787621 Receives reassigned benefits from 5 practitioners
Practice locations: Fresno, CA
O20181102000650 CA DME Supplier - Physician - General SurgeryDME Supplier - Physician - Chiropractic 2264787621 Practice locations: Fresno, CA

National Provider Directory

National Provider Directory

Locations

5150 N 6th St
Ste 100
Fresno, CA 93710
Phone (559) 222-5362

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1395792000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1395792000000",
    "number": "1972920098",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5150 N 6TH ST STE 100",
            "city": "FRESNO",
            "state": "CA",
            "postal_code": "937107505",
            "telephone_number": "559-222-5362",
            "fax_number": "559-222-5028"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5150 N 6TH ST STE 100",
            "city": "FRESNO",
            "state": "CA",
            "postal_code": "937107505",
            "telephone_number": "559-222-5362"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIVINE MEDICAL WELLNESS CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-26",
        "last_updated": "2014-03-26",
        "status": "A",
        "authorized_official_last_name": "ROULUND",
        "authorized_official_first_name": "RANDALL",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "559-222-5362",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DC"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Divine Medical Wellness Center",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Fresno, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.