Provider Demographics
NPI:1730639204
Name:TEQUESTA BRACING
Entity Type:Organization
Organization Name:TEQUESTA BRACING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BUITRAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-271-3030
Mailing Address - Street 1:151 E 1ST ST STE 141
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2701
Mailing Address - Country:US
Mailing Address - Phone:307-271-3030
Mailing Address - Fax:307-333-0082
Practice Address - Street 1:151 E 1ST ST STE 141
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2701
Practice Address - Country:US
Practice Address - Phone:307-271-3030
Practice Address - Fax:307-333-0082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-09
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies