Provider Demographics
NPI:1114524824
Name:FAODAIL PAIN MANAGEMENT, PLLC
Entity Type:Organization
Organization Name:FAODAIL PAIN MANAGEMENT, PLLC
Other - Org Name:FULL LIFE PAIN AND DEPRESSION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, DNP, MSN
Authorized Official - Phone:603-309-3902
Mailing Address - Street 1:252 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2613
Mailing Address - Country:US
Mailing Address - Phone:603-448-1941
Mailing Address - Fax:
Practice Address - Street 1:151 ROUTE 10 N UNIT 2
Practice Address - Street 2:
Practice Address - City:GRANTHAM
Practice Address - State:NH
Practice Address - Zip Code:03753-3621
Practice Address - Country:US
Practice Address - Phone:603-309-3902
Practice Address - Fax:603-843-8176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty