Healthcare Provider Details

I. General information

NPI: 1528576436
Provider Name (Legal Business Name): KOA CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 07/03/2024
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-5995 KUAKINI HWY STE 213
KAILUA KONA HI
96740-2120
US

IV. Provider business mailing address

75-5995 KUAKINI HWY STE 213
KAILUA KONA HI
96740-2120
US

V. Phone/Fax

Practice location:
  • Phone: 808-638-3343
  • Fax: 844-308-3545
Mailing address:
  • Phone: 808-638-3343
  • Fax: 844-308-3545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number258
License Number StateHI

VIII. Authorized Official

Name: DR. CORINNE MAUL DE SOTO
Title or Position: PRESIDENT
Credential: ND
Phone: 808-638-3343