Provider Demographics
NPI:1275228090
Name:WILSON, KALMECE TEHRAN
Entity Type:Individual
Prefix:
First Name:KALMECE
Middle Name:TEHRAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 BROADWAY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0713
Mailing Address - Country:US
Mailing Address - Phone:270-349-3546
Mailing Address - Fax:
Practice Address - Street 1:425 BROADWAY ST STE 201
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-0713
Practice Address - Country:US
Practice Address - Phone:270-349-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist