Healthcare Provider Details

I. General information

NPI: 1962353797
Provider Name (Legal Business Name): LUMINATE MEDICAL MSO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2026
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 MADISON AVE STE 11225
NEW YORK NY
10016-5101
US

IV. Provider business mailing address

169 MADISON AVE STE 11225
NEW YORK NY
10016-5101
US

V. Phone/Fax

Practice location:
  • Phone: 855-600-0479
  • Fax: 888-522-6358
Mailing address:
  • Phone: 855-600-0479
  • Fax: 888-522-6358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. TANYA L GOLOVANOFF
Title or Position: VP PHARMACY & CARE DELIVERY
Credential: GOLOVANOFF
Phone: 720-412-2583