Healthcare Provider Details

I. General information

NPI: 1093057226
Provider Name (Legal Business Name): AQUA VISION CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 REISTERSTOWN RD
PIKESVILLE MD
21208-4206
US

IV. Provider business mailing address

1006 REISTERSTOWN RD
PIKESVILLE MD
21208-4206
US

V. Phone/Fax

Practice location:
  • Phone: 410-602-1567
  • Fax: 410-602-1568
Mailing address:
  • Phone: 410-602-1567
  • Fax: 410-602-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1714
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTA1714
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberTA1714
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberTA1714
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberTA1714
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberTA1714
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberTA1714
License Number StateMD

VIII. Authorized Official

Name: DR. KELECHI MEZU
Title or Position: DIRECTOR
Credential: OD, DR.PH
Phone: 410-602-1567