Provider Demographics
NPI:1649939539
Name:DIRECT CONNECT VENTURES LLC
Entity type:Organization
Organization Name:DIRECT CONNECT VENTURES LLC
Other - Org Name:
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 STE 132
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6545
Mailing Address - Country:US
Mailing Address - Phone:602-362-5100
Mailing Address - Fax:
Practice Address - Street 1:26 E BASELINE RD STE 132
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6545
Practice Address - Country:US
Practice Address - Phone:602-362-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ069683Medicaid