Laserfiche WebLink
II. COMPANY DETAILS <br />1. NAME OF AGENCY: RG Ambulance Service, Inc. d/b/a American Ambulance Sel <br />MAILING ADDRESS: 2766 NW 62nd Street <br />CITY Miami <br />COUNTY—Miami-Dade <br />ZIP CODE: 33147 BUSINESS PHONE: 305-779-0505 <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />Private <br />3. MANAGER'S NAME: Michael DeSouza <br />ADDRESS: 4227 St. Lucie Blvd. Ft. Pierce, FL 34946 <br />PHONE #: 772-465-1111 <br />4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a <br />separate sheet if necessary): <br />NAME ADDRESS <br />RAY GONZALEZ 2766 NW 62ND STREET MIAMI FL 33147 <br />CEO <br />RENE GONZALEZ 2766 NW 62ND STREET MIAMI FL 33147 CFO <br />5 <br />NAME <br />POSITION <br />PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />ADDRESS <br />PHONE # <br />Willie Bermudez 11380 SW Village Parkway Suite 100 Port St. Lucie FL 34987 (772) 301-6500 <br />David Hall 1201 SE Indian Street Stuart FL 34997 (772) 403-4500 <br />John Salvesen 989 SW Mcdevitt Ave Port St. Lucie FI 34953 (772) 577-1755 <br />UABeth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc 22 <br />