Healthcare Provider Details

I. General information

NPI: 1952920555
Provider Name (Legal Business Name): KOA COMMUNITY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2020
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 Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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