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II. COMPANY DETAILS <br />1. NAME OF AGENCY: Coastal Care Corporation DBA Cleveland Clinic Advanced Medical Transport <br />MAILING ADDRESS: P.O. Box 9010 <br />CITY Stuart COUNTY Martin <br />ZIP CODE: 34995 BUSINESS PHONE: 772-223-5945 ext. 17028 <br />2. TYPE OF OWNERSHIP (i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />Not -for -Profit Hospital <br />3. MANAGER'S NAME: Brittany Heaton <br />ADDRESS: P.Q. Box 9010, Stuart, FL 34995 <br />PHONE #: 954-299-1432 <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 <br />See attached sheet <br />ADDRESS <br />POSITION <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />Chris Kammel, EMS Chief 800 SE Monterey Rd. Stuart, FL 34994 772-215-4495 <br />Brian Gonzalez, Division Chief 5160 NW Milner Dr. Port St. Lucie, FL 34983 772-621-3447 <br />Jonathan Huneycut, Battalion Chief 800 Martin Luther King jr. Blvd. Stuart,FL 34994 772-288-5361 <br />WFIRE ADMIN ASSISTANTS1Beth\Beth Casano EOMCOPCNIRENEWAL PACKETS\COPCN Application.doc 2 <br />44 <br />