MEDICARE: HAVEN MINISTRIES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	200301378	NC

General Provider Information

NPI Number	:	1306171244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN MINISTRIES, INC.

Provider Business Mailing Address
First Line	:	7212 OYSTER LN
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28411-7132
Country	:	US
Telephone Number	:	910-803-1620
Fax Number	:	484-315-2387

Provider Business Practice Location Address
First Line	:	400 FLEMINGTON DRIVE
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-2512
Country	:	US
Telephone Number	:	910-803-1620
Fax Number	:	484-315-2387

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. DWIGHT LYSNE
Credential	:	M.D., M.DIV.
Telephone Number	:	910-803-1620

Provider Enumeration Date	:	10/09/2009
Last Update Date	:	10/09/2009

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