Healthcare Provider Details

I. General information

NPI: 1164385753
Provider Name (Legal Business Name): SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 WILLIAMSON COUNTY PKWY STE B
MARION IL
62959-5287
US

IV. Provider business mailing address

109 CALIFORNIA ST
CARTERVILLE IL
62918-1923
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9200
  • Fax:
Mailing address:
  • Phone: 618-519-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA CARNEY
Title or Position: CEO
Credential:
Phone: 618-985-8221