Provider Demographics
NPI:1972920098
Name:DIVINE MEDICAL WELLNESS CENTER INC
Entity type:Organization
Organization Name:DIVINE MEDICAL WELLNESS CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ROULUND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:559-222-5362
Mailing Address - Street 1:5150 N 6TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-7505
Mailing Address - Country:US
Mailing Address - Phone:559-222-5362
Mailing Address - Fax:559-222-5028
Practice Address - Street 1:5150 N 6TH ST STE 100
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7505
Practice Address - Country:US
Practice Address - Phone:559-222-5362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty