Healthcare Provider Details

I. General information

NPI: 1295123164
Provider Name (Legal Business Name): DIRECT CONNECT VENTURES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 E WARNER RD SUITE 111
PHOENIX AZ
85044-3311
US

IV. Provider business mailing address

2320 E BASELINE RD STE 148473
PHOENIX AZ
85042-6951
US

V. Phone/Fax

Practice location:
  • Phone: 480-245-6066
  • Fax:
Mailing address:
  • Phone: 520-371-3782
  • Fax: 866-624-2580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberOTC6888
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. IVORY KAIMARON PRICE
Title or Position: CEO
Credential:
Phone: 520-371-3782