Healthcare Provider Details

I. General information

NPI: 1508502774
Provider Name (Legal Business Name): ELITE EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 MCINGVALE RD STE 104
HERNANDO MS
38632-5935
US

IV. Provider business mailing address

717 BURTON LN
SOUTHAVEN MS
38671-6977
US

V. Phone/Fax

Practice location:
  • Phone: 662-612-2020
  • Fax:
Mailing address:
  • Phone: 662-934-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. EMILY RIDGE
Title or Position: OPTOMETRIST
Credential: OD
Phone: 662-612-2020