Provider Demographics
NPI:1912240938
Name:EVMARK CORP
Entity Type:Organization
Organization Name:EVMARK CORP
Other - Org Name:EXTENDED FAMILY ASSISTED LIVING HOMES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-833-6328
Mailing Address - Street 1:1942 N CALLE MADERAS
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2908
Mailing Address - Country:US
Mailing Address - Phone:480-833-6328
Mailing Address - Fax:480-827-9178
Practice Address - Street 1:2556 E HERMOSA VISTA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-2304
Practice Address - Country:US
Practice Address - Phone:480-833-6328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-1203310400000X
AZAL4343H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ219747Medicaid
AZ219819Medicaid