Healthcare Provider Details

I. General information

NPI: 1356677058
Provider Name (Legal Business Name): SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 WILLIAMSON COUNTY PKWY
MARION IL
62959-5235
US

IV. Provider business mailing address

109 CALIFORNIA STREET PO BOX 577
CARTERVILLE IL
62918-0577
US

V. Phone/Fax

Practice location:
  • Phone: 618-969-8600
  • Fax: 618-997-1214
Mailing address:
  • Phone: 618-985-8221
  • Fax: 618-985-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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