Provider Demographics
NPI:1528576436
Name:KOA CLINIC, INC
Entity Type:Organization
Organization Name:KOA CLINIC, INC
Other - Org Name:KOA CLINIC OF INTEGRATIVE HEALING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUL DE SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:808-638-3343
Mailing Address - Street 1:75-5995 KUAKINI HWY STE 445
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2123
Mailing Address - Country:US
Mailing Address - Phone:808-638-3343
Mailing Address - Fax:844-308-3545
Practice Address - Street 1:75-5995 KUAKINI HWY STE 445
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2123
Practice Address - Country:US
Practice Address - Phone:808-638-3343
Practice Address - Fax:844-308-3545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X, 261QP2300X
HI258261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care