Healthcare Provider Details

I. General information

NPI: 1538072814
Provider Name (Legal Business Name): KOLOA DPC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5460 KOLOA RD STE G2O2
KOLOA HI
96756-9421
US

IV. Provider business mailing address

PO BOX 1887
KOLOA HI
96756-1887
US

V. Phone/Fax

Practice location:
  • Phone: 802-355-7479
  • Fax:
Mailing address:
  • Phone: 802-355-7479
  • Fax: 808-309-6625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MOLLY REBECCA HEUBLEIN
Title or Position: MD
Credential: MD
Phone: 802-355-7479