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General NPI Number Information
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NPI Number | 1952920555
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Entity Type | Organization
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Legal Business Name | KOA COMMUNITY CLINIC, INC
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Dates
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Enumeration Date | 04/13/2020
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Last Update Date | 07/03/2024
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Provider Practice Location Address
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Address Line | 75-5995 KUAKINI HWY STE 213
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City | KAILUA KONA
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State | HI
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Zip | 96740-2120
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Country | US
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Telephone | 808-638-3343
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Fax | 844-308-3545
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Provider Business Mailing Address
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Address Line | 75-5995 KUAKINI HWY STE 213
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City | KAILUA KONA
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State | HI
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Zip | 96740-2120
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Country | US
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Telephone | 808-638-3343
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Fax | 844-308-3545
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. CORINNE MAUL DE SOTO
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Credential |
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Telephone | 808-638-3343
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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