Healthcare Provider Details

I. General information

NPI: 1174859870
Provider Name (Legal Business Name): SHAWNEE HEALTH SERVICE & DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S. LEWIS LANE
CARBONDALE IL
62901
US

IV. Provider business mailing address

109 CALIFORNIA ST PO BOX 577
CARTERVILLE IL
62918-1923
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9901
  • Fax:
Mailing address:
  • Phone: 618-985-8221
  • Fax: 618-985-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name: CHRISTINA CARNEY
Title or Position: CEO
Credential:
Phone: 618-956-9521