Provider Demographics
NPI:1831066885
Name:AZ ADVANCED TBI DIAGNOSTICS LLC
Entity type:Organization
Organization Name:AZ ADVANCED TBI DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-300-9561
Mailing Address - Street 1:1775 W UNIVERSITY DR STE 127
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-3254
Mailing Address - Country:US
Mailing Address - Phone:520-300-9561
Mailing Address - Fax:
Practice Address - Street 1:3970 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-1460
Practice Address - Country:US
Practice Address - Phone:520-300-9561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty