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General NPI Number Information
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NPI Number | 1619829900
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Entity Type | Organization
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Legal Business Name | AQUA BLUE PEDIATRICS PLLC
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Dates
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Enumeration Date | 02/10/2026
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Last Update Date | 02/10/2026
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Provider Practice Location Address
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Address Line | 785 W GRANADA BLVD STE 4
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City | ORMOND BEACH
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State | FL
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Zip | 32174-5163
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Country | US
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Telephone | 630-464-4928
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Fax |
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Provider Business Mailing Address
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Address Line | 7901 4TH ST N # 30729
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City | ST PETERSBURG
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State | FL
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Zip | 33702-4305
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Country | US
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Telephone | 630-464-4928
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Fax | 847-854-9403
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | BRANDON BETANCOURT
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Credential |
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Telephone | 847-854-9402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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