NPIMap

Organization Active NPI

Faodail Pain Management, PLLC

Doing business as Full Life Pain and Depression Center

  • Pain Medicine Physician
  • Grantham, NH
National Provider Identifier
1114524824
Registry record updated Jul 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Medicine PhysicianTaxonomy code 208VP0000X
Legal business name
FAODAIL PAIN MANAGEMENT, PLLC
Doing business as
Full Life Pain and Depression Center
Practice address
151 Route 10 N Unit 2
Grantham, NH 03753-3621
Phone
(603) 309-3902
Fax
(603) 843-8176
NPI assigned
Oct 6, 2020
Last updated
Jul 25, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 25, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Melynda Wallace, CRNA, DNP, MSNNPI 1881672137
Title
Owner
Phone
(603) 309-3902

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine Physician 208VP0000X NU Primary

Addresses

Primary practice location

151 Route 10 N Unit 2
Grantham, NH 03753-3621

Mailing address

252 Mechanic St
Lebanon, NH 03766-2613
Phone (603) 448-1941

Other names 1

  • Full Life Pain and Depression Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201209002105 NH Part B Supplier - Clinic/Group Practice 6406268861 Receives reassigned benefits from 1 practitioner
Practice locations: Grantham, NH

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1601942400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690243200000",
    "number": "1114524824",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "252 MECHANIC ST",
            "city": "LEBANON",
            "state": "NH",
            "postal_code": "037662613",
            "telephone_number": "603-448-1941"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "151 ROUTE 10 N UNIT 2",
            "city": "GRANTHAM",
            "state": "NH",
            "postal_code": "037533621",
            "telephone_number": "603-309-3902",
            "fax_number": "603-843-8176"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAODAIL PAIN MANAGEMENT, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-10-06",
        "last_updated": "2023-07-25",
        "certification_date": "2023-07-25",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "MELYNDA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "603-309-3902",
        "authorized_official_credential": "CRNA, DNP, MSN"
    },
    "taxonomies": [
        {
            "code": "208VP0000X",
            "taxonomy_group": "",
            "desc": "Pain Medicine, Pain Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Full Life Pain and Depression Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grantham, NH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.