Healthcare Provider Details

I. General information

NPI: 1720960867
Provider Name (Legal Business Name): LAWRENCE BRAVO DEVERA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4259 E CARMEL PRIVADO
ONTARIO CA
91761-0639
US

IV. Provider business mailing address

18101 KRAMERIA AVE
RIVERSIDE CA
92508-8218
US

V. Phone/Fax

Practice location:
  • Phone: 323-250-9489
  • Fax:
Mailing address:
  • Phone: 323-369-8646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC37367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: