Healthcare Provider Details

I. General information

NPI: 1619829900
Provider Name (Legal Business Name): AQUA BLUE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 W GRANADA BLVD STE 4
ORMOND BEACH FL
32174-5163
US

IV. Provider business mailing address

7901 4TH ST N # 30729
ST PETERSBURG FL
33702-4305
US

V. Phone/Fax

Practice location:
  • Phone: 630-464-4928
  • Fax:
Mailing address:
  • Phone: 630-464-4928
  • Fax: 847-854-9403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDON BETANCOURT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 847-854-9402