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II. COMPANY DETAILS <br />1. NAME OF AGENCY: Coastal Health Systems of Brevard, Inc. <br />MAILING ADDRESS: 486 Gus Hipp Blvd <br />CITY Rockledge COUNTY Brevard <br />ZIP CODE: 32955 BUSINESS PHONE: (321)633-7050 <br />2. TYPE OF OWNERSHIP (i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />Private <br />3 <br />MANAGER'S NAME: Brooke Taylor <br />ADDRESS: 486 Gus Hipp Blvd Rockledge, FL 32955 <br />PHONE #: (321) 633-7050 Ext -100 <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 POSITION <br />Monica Van Leeuwen 486 Gus Hipp Blvd Rockledge, FI 32955 CFO <br />Brooke Taylor 486 Gus Hipp Blvd Rockledge, FL 32955 CEO/President <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />Brevard Fire Rescue 1040 S. Florida Ave Rockledge, FL 32955 (321) 633-2056 <br />Health First 6450 US 1 Rockledge, FL 32955 (321) 434-4300 <br />Parrish Medical Center 951 N. Washington Ave Titusville, FL 32796 (321) 268-6111 <br />UAFIRE ADMIN ASSISTANTS\Beth\Beth Casano EOC\COPCMRENEWAL PACKETS\COPCN Application.doc 2 <br />100 <br />