Provider Demographics
NPI:1730553058
Name:DIRECT CONNECT VENTURES LLC
Entity type:Organization
Organization Name:DIRECT CONNECT VENTURES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IVORY
Authorized Official - Middle Name:KAIMARON
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-371-3782
Mailing Address - Street 1:26 E BASELINE RD
Mailing Address - Street 2:SUITE 132
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6951
Mailing Address - Country:US
Mailing Address - Phone:602-362-5100
Mailing Address - Fax:928-646-7153
Practice Address - Street 1:1760 E VILLA DR STE A
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4679
Practice Address - Country:US
Practice Address - Phone:520-371-3782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-24
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QM0801X, 261QM0850X, 261QM0855X, 385H00000X, 385HR2055X
AZOTC6593251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1548741812Medicaid
AZ1649939539Medicaid